|
0
<br />4
<br />0�
<br />(O
<br />.3 .
<br />TYPEIPRINT
<br />IN
<br />PERMANENT
<br />SLACK INK.
<br />FOR
<br />INSTRUCTIONS
<br />SEE HANDBOOK.
<br />'/s aao
<br />No soma, r la.ml
<br />PARENTS
<br />INFORMANT
<br />DISPOSITION
<br />MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
<br />CERTIFICATE OF DEATH STATE FILE NUMBER
<br />/ 1
<br />REGISTRATION 171STRI(T Nn i f 1 RFr; I.CTpAp'C NIIMRFr] .0 �/ 1 124-
<br />1. OECEOBNT'S NAME (First, Middle, Last)
<br />2. SEX
<br />1 GATE OF DEATH (Month, Day, year)
<br />WILMA LOUISE VanMETER
<br />m
<br />_
<br />-..•
<br />c7=5
<br />�:
<br />m
<br />5. DATE OF BIRTH (Month, Day, Year)
<br />7. BIRTHPLACE (City and State or Foreign Counl W
<br />'N1H6 Dnra
<br />err}+
<br />511 -24 -6904
<br />76'dayNets)
<br />Jan. 20, 1928 ITwo
<br />Buttes, Colo
<br />6. WAS DECEDENT EVER IN
<br />U.S. ARMED FORCES?
<br />9a. PLACE OF DEATH (Check only one)
<br />P
<br />HOSPITAL: ❑ Inpatient [] ER/Outpatient ❑ DOA OTHER: ❑ Nursing Home W Residence ❑ Other (Specify)
<br />9b. FACILITY NAME (fl not institution, give street and number)
<br />sr„ CITY, TOWN, OR LOCATION OF DEATH
<br />9d, COUNTY OF DEATH
<br />Branson
<br />Taney
<br />M
<br />a
<br />re
<br />=
<br />n
<br />CA
<br />work done during most or workhrV His. Do not use retired.)
<br />married
<br />Ro n
<br />90 DAYS?
<br />Ise. RESIDENCE - STATE
<br />13b. COUNTY
<br />Cn
<br />Missouri
<br />Taney
<br />1 2
<br />13e. STREET AND NUMBER
<br />Cn
<br />139. YEARS AT PRESENT ADDRESS
<br />,
<br />pp>�
<br />2 3,y
<br />❑Under 5 ❑ 5 -9 10-19 ❑ 20 Or more
<br />14, WAS DECEDENT OF HISPANIC ORIGIN
<br />15. RACE - American Indian, Black, Whlte, etc
<br />16. DECEDENT'S EDUCATION
<br />(Specify No or Yes - If yea, specify Cuban, Mexican, Puerto Rican, etc.)
<br />(Specify)
<br />(Specify only highest grade completed)
<br />Elements !Secondary (0 -12)
<br />-�2-
<br />College (1 -4 yr 5 +)
<br />-0-
<br />0
<br />ND ❑ Yes specify:
<br />White
<br />17, FATHER'S NAME (Flat, Middle, Ls$0
<br />1B. MOTHER'S NAME (First, Middle, Malden Surname)
<br />,RRoy Murphey
<br />L7 Natural ❑ Pending
<br />rT"I
<br />_
<br />�
<br />20a. BURIAL, CREMATION,
<br />20b. DATE OF DISPOSITION
<br />20c, PLACE OF DISPOSITION (Name or Cemetery, Crematory, or
<br />LOCATION (City or Town, Slate)
<br />OTHER (S
<br />Cremation
<br />NMI' 1MV 1. Da j ar) �p04
<br />(] I 1
<br />120d.
<br />other place)
<br />.
<br />r
<br />22a. AME AND Aq ESS OF F CILlrY
<br />Snapp- 'earrd°en Funeral Home
<br />�
<br />Wd4 (
<br />1638 E. Hwy 76 Branson, Mo. 65616
<br />2000149925
<br />building, etc. (spectlN
<br />�
<br />C.^i
<br />26a, tspeelly)
<br />beg! of my knowledge, death occurred at the tlm and lace antl due to the cause(s) stated.
<br />20c. OATC SIGNED
<br />2Bd. TIME OF DEATH
<br />L_r CERTIFYING PHYSICIAN
<br />F11,T,
<br />ture and Title) �
<br />(Mon , Day, er)
<br />I
<br />/S O 4
<br />+c+0 M
<br />0
<br />❑ MEDICAL EXAMINERICORONER
<br />7
<br />f
<br />Cn
<br />29a, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER OR CORONER) (Type r Prim)
<br />29b, MO. LICENSE NUMBER
<br />30, WAS CASE REF RED TO MEDICAL EXAMINER/CORONER7
<br />'
<br />W 11.t"e laM LEr L �L" 21 M � q Nla►"J�
<br />Lf
<br />Gr>
<br />z
<br />31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />32. R IS AR'S SIGNATURE
<br />33. DATE RECEIVED BY LOCAL REGISTRAR
<br />(Type or Print)
<br />J���%
<br />(Month, Day, Year) J
<br />C'
<br />.3 .
<br />TYPEIPRINT
<br />IN
<br />PERMANENT
<br />SLACK INK.
<br />FOR
<br />INSTRUCTIONS
<br />SEE HANDBOOK.
<br />'/s aao
<br />No soma, r la.ml
<br />PARENTS
<br />INFORMANT
<br />DISPOSITION
<br />MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
<br />CERTIFICATE OF DEATH STATE FILE NUMBER
<br />/ 1
<br />REGISTRATION 171STRI(T Nn i f 1 RFr; I.CTpAp'C NIIMRFr] .0 �/ 1 124-
<br />1. OECEOBNT'S NAME (First, Middle, Last)
<br />2. SEX
<br />1 GATE OF DEATH (Month, Day, year)
<br />WILMA LOUISE VanMETER
<br />Female
<br />Nov. 17, 2004
<br />4. SOCIAL SECURITY NO.
<br />Se. AGE • Lest
<br />511. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />5. DATE OF BIRTH (Month, Day, Year)
<br />7. BIRTHPLACE (City and State or Foreign Counl W
<br />'N1H6 Dnra
<br />I -UR3 I MI111TE6
<br />511 -24 -6904
<br />76'dayNets)
<br />Jan. 20, 1928 ITwo
<br />Buttes, Colo
<br />6. WAS DECEDENT EVER IN
<br />U.S. ARMED FORCES?
<br />9a. PLACE OF DEATH (Check only one)
<br />❑Yes Me ❑Unk,
<br />HOSPITAL: ❑ Inpatient [] ER/Outpatient ❑ DOA OTHER: ❑ Nursing Home W Residence ❑ Other (Specify)
<br />9b. FACILITY NAME (fl not institution, give street and number)
<br />sr„ CITY, TOWN, OR LOCATION OF DEATH
<br />9d, COUNTY OF DEATH
<br />123 Stone Circle
<br />Branson
<br />Taney
<br />10. MARITAL STATUS - Marred, Never
<br />11. SURVIVING SPOUSE'S NAME
<br />12a. DECEDENTS USUAL OCCUPATION (dive kind of
<br />12h. KIND OF BUSINESS OR INDUSTRY
<br />Married. Widowed. Divon:ad, (SPad'y)
<br />(II wile, g.. lull maidan Hama)
<br />work done during most or workhrV His. Do not use retired.)
<br />married
<br />Ro n
<br />90 DAYS?
<br />Ise. RESIDENCE - STATE
<br />13b. COUNTY
<br />13c. CITY, TOWN, OR LOCATION 13d. ZIP CODE
<br />Missouri
<br />Taney
<br />1 2
<br />13e. STREET AND NUMBER
<br />131. INSIDE CITY LIMITS
<br />139. YEARS AT PRESENT ADDRESS
<br />123 Stone Circle
<br />2 �
<br />❑ Yee No
<br />2 3,y
<br />❑Under 5 ❑ 5 -9 10-19 ❑ 20 Or more
<br />14, WAS DECEDENT OF HISPANIC ORIGIN
<br />15. RACE - American Indian, Black, Whlte, etc
<br />16. DECEDENT'S EDUCATION
<br />(Specify No or Yes - If yea, specify Cuban, Mexican, Puerto Rican, etc.)
<br />(Specify)
<br />(Specify only highest grade completed)
<br />Elements !Secondary (0 -12)
<br />-�2-
<br />College (1 -4 yr 5 +)
<br />-0-
<br />0
<br />ND ❑ Yes specify:
<br />White
<br />17, FATHER'S NAME (Flat, Middle, Ls$0
<br />1B. MOTHER'S NAME (First, Middle, Malden Surname)
<br />,RRoy Murphey
<br />L7 Natural ❑ Pending
<br />19a. INFORMANTS NAME (TypeiPnnt)
<br />ISb. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, State. Zip Cede)
<br />20a. BURIAL, CREMATION,
<br />20b. DATE OF DISPOSITION
<br />20c, PLACE OF DISPOSITION (Name or Cemetery, Crematory, or
<br />LOCATION (City or Town, Slate)
<br />OTHER (S
<br />Cremation
<br />NMI' 1MV 1. Da j ar) �p04
<br />(] I 1
<br />120d.
<br />other place)
<br />21. SIGNATURE OF FUNERAL SERVICE LICENSEE OR
<br />PERSON ACTING AS SUCH
<br />22a. AME AND Aq ESS OF F CILlrY
<br />Snapp- 'earrd°en Funeral Home
<br />2b. FUNERAL ESTABLISHMENT
<br />LICENSE NUMBER
<br />Wd4 (
<br />1638 E. Hwy 76 Branson, Mo. 65616
<br />2000149925
<br />23. PART I. En or the diseases, Injuries, pr compllc ons that caused the death. Do not enter the mode of dying, such as cardiac or respiratory areal, shock, or heart failure. ' Apprpxlmate Interval Between
<br />IMMEDIATE CAUSE ceuion ea�h line.�� r A� A'UC - - l _ ' Onset and Death
<br />�•y6`,� t a.
<br />(Final disease r
<br />. _ DUE TO (OR AS A CONSEQUENCE OF)' �
<br />': .' THIS IS A CERTIFIED COPY OF AN ORIGINAL DOCUMENT
<br />w.'. �� (Do not accept if rephotographed, or if seal impression cannot be felt.)
<br />THE REPROD�°TIO F °THIS RQ,CILI r1 i' f�ITED BY LAW (sec. 193245,193.255, & 193.315 RSMo 1994).
<br />STATE OF N s^ y�' r r•
<br />I HtgR.WY'4ERTIFY that this is an exact reproduction of the certificate for the person named therein as it now appears in the permanent
<br />records of tc, E reau of Vital- Rt Ss bf1he MisOI�RD4artment of Health and Senior Services. Witness my hand as County Registrar of Vital Statistics and the Seal of the Missouri
<br />Departmentaf f;wI6 and'9erijb irkes,this dZfe -v
<br />r
<br />rno sso -110 (10 -o1I egistrar of Vital Statistic
<br />j/ILIXn
<br />In death)
<br />b.
<br />Sequentially list
<br />conditions, it any,
<br />DUE TO (OR AS A CONSEQUENCE OF):
<br />leading to Immediate
<br />cause. Enter
<br />UNDERLYING CAUSE
<br />(dieeaea or injury dot
<br />C. I
<br />DUE TO (OR AS A CONSEQUENCE OF): '
<br />initiated events resulting
<br />in death) LAST
<br />d. i
<br />PART IL Other significant conditions Contributing to death but not resulting In the underlying cause given in Part I.
<br />24. IF DECEASED WAS
<br />a. WAS AN AUTOPSY
<br />25b. WERE AUTOPSY FINDINGS
<br />FEMALE 10 -49, WAS SHE
<br />PCRFORMEO7
<br />AVAILABLE PRIOR TO
<br />PREGNANT IN THE LAST
<br />COMPLETION OF CAUSE OF
<br />90 DAYS?
<br />DEATH?
<br />1 2
<br />1
<br />1 2
<br />❑ Yes ❑ No ❑ Unk.
<br />❑ Yes No
<br />❑ Yes ❑ No
<br />26. MANNER OF DEATH
<br />27a. DATE OF INJURY
<br />27b. TIME OF
<br />27c. INJURY AT WORK?
<br />27d. DESCRIBE HOW INJURY OCCURRED
<br />,�/
<br />(Mgnrh, Day. year)
<br />INJURY
<br />L7 Natural ❑ Pending
<br />Investigation
<br />El Accident
<br />M
<br />1 2
<br />11 Yes El ❑Unk.
<br />27e. PLACE OF INJURY - At home, Farm street, factory, office 271.
<br />LOCATION ( Street and Number or Rural Route Number, City or Town, Stele)
<br />❑ SUICIde ❑ Could be
<br />not
<br />Determined
<br />building, etc. (spectlN
<br />El Homicide
<br />26a, tspeelly)
<br />beg! of my knowledge, death occurred at the tlm and lace antl due to the cause(s) stated.
<br />20c. OATC SIGNED
<br />2Bd. TIME OF DEATH
<br />L_r CERTIFYING PHYSICIAN
<br />F11,T,
<br />ture and Title) �
<br />(Mon , Day, er)
<br />I
<br />/S O 4
<br />+c+0 M
<br />0
<br />❑ MEDICAL EXAMINERICORONER
<br />7
<br />29a, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER OR CORONER) (Type r Prim)
<br />29b, MO. LICENSE NUMBER
<br />30, WAS CASE REF RED TO MEDICAL EXAMINER/CORONER7
<br />W 11.t"e laM LEr L �L" 21 M � q Nla►"J�
<br />Lf
<br />El i o
<br />Yes
<br />31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />32. R IS AR'S SIGNATURE
<br />33. DATE RECEIVED BY LOCAL REGISTRAR
<br />(Type or Print)
<br />J���%
<br />(Month, Day, Year) J
<br />': .' THIS IS A CERTIFIED COPY OF AN ORIGINAL DOCUMENT
<br />w.'. �� (Do not accept if rephotographed, or if seal impression cannot be felt.)
<br />THE REPROD�°TIO F °THIS RQ,CILI r1 i' f�ITED BY LAW (sec. 193245,193.255, & 193.315 RSMo 1994).
<br />STATE OF N s^ y�' r r•
<br />I HtgR.WY'4ERTIFY that this is an exact reproduction of the certificate for the person named therein as it now appears in the permanent
<br />records of tc, E reau of Vital- Rt Ss bf1he MisOI�RD4artment of Health and Senior Services. Witness my hand as County Registrar of Vital Statistics and the Seal of the Missouri
<br />Departmentaf f;wI6 and'9erijb irkes,this dZfe -v
<br />r
<br />rno sso -110 (10 -o1I egistrar of Vital Statistic
<br />j/ILIXn
<br />
|