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OFFICE of VITAL STATISTICS
<br />CERTIFIED COPY
<br />2"-212622-
<br />TYPE OR
<br />Hernando
<br />I Brooksville
<br />20c. LOCATION - City or Town, State '
<br />PRINT IN
<br />Road
<br />CERTIFICATE OF DEATH
<br />13f. ZIP CODE
<br />_RMANENT
<br />LACK INK
<br />LOCAL FILE NO.
<br />FLORIDA
<br />LIMITS ?(Yes or No)
<br />OF DEATH? (Yes or No)
<br />1. DECEDENT'S NAME FIRST
<br />MIDDLE LAST
<br />(Specify only highest grade completed)
<br />2. SEX
<br />PER ACTING AS SUCH
<br />Phyllis
<br />Ann Schuele
<br />Elementary /Secondary
<br />Female
<br />No
<br />3. DATE OF DEATH (Month, Day, Year)
<br />4. SOCIAL SECURITY NUMBER
<br />5a. AGE -Last Birthday
<br />5b. UNDER
<br />1 YEAR
<br />Sc. UNDER 1 Da
<br />32b. TIME OF
<br />Au ust 15 2001
<br />508 -30 -4251
<br />(years)
<br />72
<br />Months
<br />Days
<br />Hours Minutes
<br />Chaloud
<br />6. DATE OF BIRTH (Month, Day, Year)
<br />7. BIRTHPLACE (City and State or Foreign Country)
<br />8. WAS DECEDENT EVER IN U.S.
<br />/
<br />June 4 1929
<br />Loo City, Nebraska
<br />RMED FORCES? (Yes or No)
<br />�Po
<br />Ia.
<br />9a. PLACE OF DEATH (Check only one: see instructions on other side)
<br />H PIT L. __ Inpatient _ ER /Out anent _DOA OTHER: %� Nursing Home _Residence _Other (Specify)
<br />9b. INSIDE CITY LIMITS? (Yes or No)
<br />Yes
<br />M
<br />9c. FACILITY NAME (If not institution, give street and
<br />number)
<br />9d. CITY, TOWN, OR LOCATION OF DEATH
<br />9e. COUNTY OF DEATH
<br />GIV
<br />GIV E KIND OF
<br />street, factory, etc. (Specify)
<br />Heartland of Brooksville
<br />Brooksville
<br />Hernando
<br />WORKDONE
<br />10a. DECEDENT'S USUAL OCCUPATION
<br />10b. KIND
<br />OF BUSINESS /INDUSTRY
<br />11. MARITAL STATUS - Married.
<br />12. SURVIVING SPOUSE (If wife, give maiden name)
<br />DURINGMOST
<br />Never Married, Widowed,
<br />OF WORKING
<br />Divorced (Specify)
<br />1
<br />LIFE DONOT
<br />USE RETIRED.
<br />Homemaker
<br />Own
<br />Home
<br />Widowed
<br />in
<br />13a. RESIDENCE - STATE
<br />I 13b. COUNTY
<br />13c. CITY, TOWN, OR LOCATION
<br />13d. STREET AND NUMBER
<br />Florida
<br />Hernando
<br />I Brooksville
<br />20c. LOCATION - City or Town, State '
<br />1 21237 Yontz
<br />Road
<br />13e. INSIDE CITY
<br />13f. ZIP CODE
<br />14. WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN?
<br />15. RACE - American Indian,
<br />16. DECEDENT'S EDUCATION
<br />LIMITS ?(Yes or No)
<br />OF DEATH? (Yes or No)
<br />(Specify No or Yes - If yes, specify Haitian, Cuban,
<br />Black, White, etc.
<br />(Specify only highest grade completed)
<br />PER ACTING AS SUCH
<br />Mexican, Puerto Rican, etc.) _( No _ Yes
<br />Specify
<br />Elementary /Secondary
<br />College (1 -4 or 5 . I
<br />No
<br />34601
<br />Specify
<br />White
<br />(D - Iy) 12
<br />31, PROBABLE MANNER OF
<br />17. FATHER'S NAME (First, Middle. Last)
<br />32b. TIME OF
<br />18. MOTHER'S
<br />NAME (First, Middle, Maiden Surname)
<br />Stephen
<br />Spotanski
<br />Julia
<br />F.
<br />Chaloud
<br />19a. INFORMANT'S NAME (Type /Print)
<br />I 19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, Stale, Zip Code)
<br />512, 9/96
<br />)laces HRS
<br />n 512)
<br />■
<br />► 4605 15010 Cortez Blvd., Brooksville, FL 34613
<br />22a. To the best my knowled e, ath occurre at a ti a tea e a due ¢ 23a. On the basis of examination and /or investigation, in my opinion death occurred
<br />to the cause(s) as stated. ° Z at the time, date and place and due to the cause(s) and manner as stated.
<br />d Fn
<br />(Signature and Title) ► y d g at and Title) ►
<br />E JLL c 22b. DATE SI )ED M ,Day, Yr) 22c. HOUR OF ATH E w 23b. DATE SIGNED (Mo., Day, Yr) 23c. HOUR OF DEATH
<br />UtZt� 12:25 P M UQ M
<br />a F 22d. NAME OF ENDIN PHYSICIAN IF OTHER THAN CERTIFIER (Type or PrinQ a 23d. MEDICAL EXAMINER'S CASE k
<br />O W O W
<br />24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER) (Type or Print)
<br />Nagi M. Kadri, M.D., 2173 Mariner B1vd.,Spring Hill, FL 34609
<br />25a. SUBREGISTRAR - SIGNATURE AND DATE 25b. L RE TRA - SI ATURE c. DATE REGISTERED
<br />26. PART I. Enter the diseases, injuries, or complications that caused the death. Di not enter the mode of dying, such as cardiac or respiratory arrest, shock Appr imate Interval
<br />or heart failure. List Only one Cause on each line. Be'. een Onset and
<br />IMMEDIATE CAUSE (Final
<br />disease or condition
<br />resulting in death) �
<br />a
<br />Sequentially list conditions,
<br />if any, leading to immediate b.
<br />cause. Enter UNDERLYING
<br />CAUSE (Disease or injury
<br />that initiated events c
<br />resulting in death) LAST
<br />\ d.
<br />20a. METHOD OF DISPOSITION
<br />20b. PLACE OF DISPOSITION (Name of cemetery, crematory, or
<br />20c. LOCATION - City or Town, State '
<br />27b. WERE AUTOPSY FINDINGS
<br />X
<br />_ Burial _ Cremation -_ Removal from State
<br />I
<br />other place)
<br />PERFORMED?
<br />1a.
<br />Donation _ Other (Specify)
<br />Trinity Memorial Gardens
<br />New Port Richey, Florida
<br />OF DEATH? (Yes or No)
<br />21a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR
<br />21b. LICENSE NUMBER
<br />21c. NAME AND ADDRESS OF FACILITY
<br />PER ACTING AS SUCH
<br />(of Licensee)
<br />Pi necrest Funeral Chapel
<br />512, 9/96
<br />)laces HRS
<br />n 512)
<br />■
<br />► 4605 15010 Cortez Blvd., Brooksville, FL 34613
<br />22a. To the best my knowled e, ath occurre at a ti a tea e a due ¢ 23a. On the basis of examination and /or investigation, in my opinion death occurred
<br />to the cause(s) as stated. ° Z at the time, date and place and due to the cause(s) and manner as stated.
<br />d Fn
<br />(Signature and Title) ► y d g at and Title) ►
<br />E JLL c 22b. DATE SI )ED M ,Day, Yr) 22c. HOUR OF ATH E w 23b. DATE SIGNED (Mo., Day, Yr) 23c. HOUR OF DEATH
<br />UtZt� 12:25 P M UQ M
<br />a F 22d. NAME OF ENDIN PHYSICIAN IF OTHER THAN CERTIFIER (Type or PrinQ a 23d. MEDICAL EXAMINER'S CASE k
<br />O W O W
<br />24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER) (Type or Print)
<br />Nagi M. Kadri, M.D., 2173 Mariner B1vd.,Spring Hill, FL 34609
<br />25a. SUBREGISTRAR - SIGNATURE AND DATE 25b. L RE TRA - SI ATURE c. DATE REGISTERED
<br />26. PART I. Enter the diseases, injuries, or complications that caused the death. Di not enter the mode of dying, such as cardiac or respiratory arrest, shock Appr imate Interval
<br />or heart failure. List Only one Cause on each line. Be'. een Onset and
<br />IMMEDIATE CAUSE (Final
<br />disease or condition
<br />resulting in death) �
<br />a
<br />Sequentially list conditions,
<br />if any, leading to immediate b.
<br />cause. Enter UNDERLYING
<br />CAUSE (Disease or injury
<br />that initiated events c
<br />resulting in death) LAST
<br />\ d.
<br />PART II. Other significant conditions contributing to death but not resulting in the
<br />27a. WAS AN AUTOPSY
<br />27b. WERE AUTOPSY FINDINGS
<br />28. CASE REPORTED
<br />underlying cause given in Part I.
<br />PERFORMED?
<br />USED TO COMPLETE CAUSE
<br />TO MEDICAL
<br />(Yes or No)
<br />OF DEATH? (Yes or No)
<br />EXAMINER?
<br />No
<br />(Yes or No) No
<br />29. IF FEMALE. WAS THERE A
<br />30a. IF SURGERY IS MENTIONED IN PART I or II, ENTER CONDITION FOR WHICH IT WAS PERFORMED
<br />30b. DATE OF SURGERY (Mo., Day, Yearl
<br />PREGNANCY IN THE PAST
<br />3 MONTHS? Yes X_ No
<br />31, PROBABLE MANNER OF
<br />32a. DATE OF INJURY
<br />32b. TIME OF
<br />32c. INJURY AT WORK?
<br />32d. DESCRIBE HOW INJURY OCCURRED
<br />(Month. Day Year)
<br />INJURY
<br />(Yes or No)
<br />SZcilY)
<br />Natural, ccident, suicide,
<br />or undetermined.
<br />M
<br />32e. PLACE OF INJURY - At home, farm,
<br />32f. LOCATION (Street and Number or Rural Route Number, City or Town, State)
<br />street, factory, etc. (Specify)
<br />THIS IS A CERTIFIED TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE
<br />AUG 17 2001
<br />BY: State Registrar
<br />THIS WAR � N' N G � OFT EOSTA�TE OF FLORIDA. DO NOTOTO PHOTOCOPIED OUT VERIFYING THE PRESENCE OF THE WATERMARK. SEAL
<br />�� !!.. THE DOCUMENT FACE CONTAINS A MULTI- COLORED BACKGROUND AND GOLD EMBOSSED SEAL. THE BACK1 �--
<br />/� 1 A/ CONTAINS SPECIAL LINES WITH TEXT AND SEALS IN THERMOCHROMIC INK.
<br />wl �/# �'� 4 ,DOH FOF& 1564A
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