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<br /> C"^' ---- ----
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<br /> 0
<br />
<br />
<br />~
<br />FOR DIVISION OF
<br />VITAL RECORDS
<br />
<br />DECEDENT
<br />
<br />PLACE OF
<br />DEATH
<br />
<br />USUAL
<br />RESIDENCE
<br />OF DECEDENT
<br />
<br /> ",M
<br /> Ii
<br /> , .~
<br /> ~ ~
<br /> ~ Ii
<br /> ;; 8'
<br /> ~2
<br /> ji
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<br />0
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<br />r
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<br /> z ~
<br /> ...
<br /> I- .~
<br /> 0:
<br /> OE
<br /> ......
<br /> !t
<br />
<br />PERSONAL
<br />DATA OF
<br />DECEDENT
<br />
<br />CAUSE OF DEATH
<br />
<br />TO
<br />PHYSICIAN:
<br />
<br />Complete and
<br />sign medical
<br />cortification
<br />(item 28) .and
<br />return ball'l
<br />copies to funeral
<br />director as soon
<br />as possiblE! aner
<br />aete(mlnation of
<br />cause.
<br />
<br />NOTE: ;1
<br />"Pending" must
<br />be indicated, SO
<br />stale in part 1
<br />and nQ1ity
<br />registrar 01 linal
<br />decision as soon
<br />as ~$ible.
<br />
<br />FUNERAL
<br />DIRECTOR
<br />
<br />REGISTRAR
<br />
<br />~
<br />N
<br />'"
<br />>
<br />
<br />2005101'1'
<br />
<br />COMMONWEALTH OF VIRGINIA - CERTIFICATE OF DEATH
<br />DEPARTMENT OF HEALTH. DIVISION OF VITAL RECORDS - RICHMOND
<br />
<br />REGISTRATION
<br />AREA NuMBER
<br />
<br />3445
<br />
<br />STATf FU,F
<br />NuMBER
<br />
<br />'-J-\
<br />\I, \
<br />Co
<br />
<br />CERTIFICATE
<br />NUMBF.A
<br />
<br />129
<br />
<br />1. FULL NAME
<br />Of DECEDENT
<br />
<br />2. SEX
<br />
<br />male female
<br />
<br />(11(51)
<br />
<br />(middle)
<br />
<br />(last)
<br />
<br />VIRGINIA
<br />
<br />
<br />o
<br />
<br />!l
<br />
<br />BERNICE
<br />
<br />KISNER
<br />
<br />3. DATE: OF (mo.) (day) (year) 4. AGE
<br />DEATH
<br />DECEMBER 10, 1999
<br />
<br />6. WAS DECEoENT
<br />EVER IN U.S ye!j. f'1o
<br />ARMEo FORCES? 0 1XI
<br />
<br />IF UNDFR , YEAR
<br />I -m~nihs - ~ - -days -
<br />earS
<br />
<br />IF UNOER 1 DAY
<br />m_--r"Y;--
<br />hOurs minutes
<br />I
<br />
<br />5, CATE OF (mo.) (day)
<br />BIRTH
<br />DEC. 3, 1920
<br />
<br />79
<br />
<br />" NAME OF HOSPITAL OR INSTITl)TION OF OFATH (if none, so Slate)
<br />
<br />B. COUNTY OF DFATH (if independp.nt cily, leave blank)
<br />
<br />Out Pal.
<br />Fmer Rm
<br />~
<br />
<br />DOA
<br />
<br />InpEl1ient
<br />
<br />o FAIRFAX
<br />
<br />. VERNON HOSPITAL
<br />
<br />o
<br />
<br />.. CITY OR TOWN OF DEAHl
<br />
<br />inside cily Or town limits'? 10. snU'::J:'" ADDRESS OR RT. NO. OF PI. ACE OF DEATH
<br />yes no
<br />
<br />AT.F.XANDRIA
<br />
<br />IJ 2501 PARKERS LANE
<br />
<br />o
<br />
<br />11. STATE (OR FOREIGN COUNTRY) OF DECEDENT'S RESIDENCE
<br />
<br />12, COUNTY OF OECEDENT'S F:I~SIDENCE (Il iMepeMef'tl cIty. leave blankl
<br />
<br />VIRGINIA
<br />
<br />FAIRFAX
<br />
<br />13 CITY DR TOWN OF RE$IDENCE
<br />
<br />IMloe city Or town limits'? 14. $r~E~T ADDRESS OR Rt, NO. OF RESIDENCE
<br />yOS no
<br />
<br />I liP CODE
<br />I
<br />'22307
<br />
<br />AT.F.XANDRIA
<br />
<br />o IJ 7107 SUSSEX PLACE
<br />
<br />15. NAME OF Of CEDENT'S FATHfR
<br />
<br />16. MAIDEN NAMt: or DECEDfNT'S MOTHER
<br />
<br />CHRISTOPHER FUEHRER
<br />
<br />KARGARET HARlE JACOBSEN
<br />
<br />17, RACE OF DECEDENT
<br />
<br />';'8&~' ~ilsrANIC onlGIN?
<br />Puer10 ~.h(;an, ate
<br />
<br />Dyes
<br />
<br />4
<br />
<br />II yes. specify CuMn, Me)(je;,an.
<br />
<br />19 EDUCATION (Specify only highest grade completed)
<br />
<br />il no
<br />
<br />WHITE
<br />
<br />ElementarylSecondary (0-12) Collp.ge (1.4 or 5 +)
<br />22, NEvER ~M~ARRIED D OIVORCED 0 23. (~~~o~~~~?e~v~ ~~~~IWED. NAME of' SpOuSE
<br />
<br />MARRIED~ WIDOWED 0 ROBERT DAVID KISNER
<br />?6. KIND OF BUSINESS OR INDUSTRY 27. INFORMANT - OR SOuRCE or INFORMATION
<br />
<br />.20. CITIZEN OF WHAT COUNTRY
<br />
<br />21, BIRTHPLACE (Slate or couniry)
<br />
<br />U.S.A.
<br />
<br />COLORADO
<br />'2,.'usciAi:-C>R LAST OCCUPATION
<br />ADMINISTRATIVE
<br />
<br />U.S. DEPT. OF NAVY
<br />
<br />ROBERT DAVID KISNER
<br />
<br />24. SOCIAL SECuRll Y NuMBER
<br />
<br />507-14-0131
<br />
<br />2e, PART I. Enter the diseases, injLJrics, or comp Ica ons il caused Itu:! aeatl'1. 00 not enter the mode oj dYing. such as cardiac or respiratory arrest, 8hoCk. or hean failure
<br />l isl only one cause on each line.
<br />
<br />INTERVAL BE1wEEN
<br />ONSET ANO OF-A TH
<br />
<br />CARDIO-PULKONARY ARREST
<br />I"'MEc~~~TI~~~e~~~i~~i~;td;~'~)~~ c~ ............... (A) OU~ "fa (OR AS A CONSt:QuENCE OF)
<br />
<br />SeCluenlially list condi!lons, ij My. loaolng
<br />to immediate cause, Enter UNDERLYING
<br />CAUSE (Disease or injury tMt Il'lihalM
<br />evMts fesulting in oeathll.AST
<br />
<br />HYPERTENSIVE HEART DISEASE
<br />
<br />(BI
<br />DUE TO (OR AS A CONSEQUENCE DF):
<br />
<br />DIABETES MELLITUS
<br />
<br />z
<br />o
<br />0::
<br />~
<br />ii:
<br />;::
<br />a:
<br />OJ
<br />o
<br />..J
<br />...
<br />o
<br />2i
<br />..
<br />:IE
<br />
<br />C
<br />PART II. ~ significant ~ conlflbul:ng to death but not resulting in the underlying l;aUSe given in Pari I.
<br />
<br />o
<br />
<br />.?6.a AUTOPSY?
<br />AuH<ORllED BY
<br />
<br />yes
<br />
<br />no
<br />E!
<br />
<br />260. IF FEMALE, WAS THERE A PREGNANCY
<br />IN PAST 3 MONTHS'
<br />
<br />?6<;.. IF EXTERNAL CAUSE:, If WAS
<br />
<br />PAt~"'A'I' 0 01 CONTRIBuTING l-J
<br />TO CAuSE Of (I~AYH
<br />
<br />280. DESCRIBE HOW INJURy RELATING TO m=ATH OCCURHE::O
<br />
<br />es 0 no 0 un\u'10wr\ 0
<br />26e. TIME OF INJURY (mo.) (day)
<br />
<br />A.M.
<br />P.M
<br />
<br />;.h:fk 0 ~~~~~le D
<br />
<br />I 28h:(City or town)
<br />I
<br />I
<br />I
<br />
<br />(statel
<br />
<br />(county)
<br />
<br />(year) 281. INJURY OCCURRED
<br />
<br />:?8g. PLACE Of' INJURY (home, farm,
<br />factory, s:reet, office bldg., otc.)
<br />
<br />
<br />28i.
<br />
<br />To tM best 01 my K
<br />
<br />(a.-m,) (p.m.) on 1M date aM place and horn the causft(s) stalM
<br />
<br />:DATE SIGNED"' \ ~ -.- f ~. \ ti a; - - - -
<br />
<br />_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.I. _ ~. .. _ _ _ _ _ _ _ _ _ _. ,. .- - - - - -:1--
<br />I ADDRESS OF" ATTENDING PHYSICIAN
<br />
<br />I 2863 Duke St. Alexandria
<br />
<br />VA. 22314
<br />
<br />29.
<br />
<br />30 PLACE
<br />OF BURIAL,
<br />REMOVAL. EtC.
<br />
<br />(name 01 cemetery or crematory)
<br />
<br />(City or county)
<br />
<br />(state)
<br />
<br />31.
<br />
<br />FAIRFAX, VIRGINIA
<br />~~~~ ~~6UNERAL DEMAINE FUNERAL HOMES, INC.
<br />SPRINGFIELD, VIRGINIA 22151
<br />I
<br />I
<br />
<br />FAIRFAX MEMORIAL PARK
<br />
<br />ADDRESS:
<br />
<br />DATE RECOAO
<br />~.. ED' "
<br />~7/~ Ie:? (J(/(J
<br />
<br />32.
<br />
<br />, . ,,";. ....
<br />This ,-i@-',b6..de'Ii.~y that this is a true and correct reproduction of
<br />the Oi:"i,.ginal re~orfl filed with the FAIRFAX COUNTY HEALTH DEPARTMENT,
<br />FAIRFAX VIRGINI~. y
<br />.. .. 'r:;
<br />
<br />::
<br />
<br />~~~
<br />/ DEPUTY REGIST R ~..
<br />
<br />\J~Y 11 ,...:ioOo;
<br />DATE ISSt!TED':.
<br />
<br />(SEAL)
<br />
<br />VOID IF ALTERED OR DOES NOT BEAR IMPRESSED SEAL
<br />
<br />LEGAL
<br />West
<br />
<br />to
<br />
<br />DESCRIPTION: Lot Nine
<br />Lawn, city of Grand
<br />
<br />(9) Block
<br />Island, Hall
<br />
<br />Eleven (II) in College
<br />County, Nebraska.
<br />
<br />Addition
<br />
|