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<br />BIRTIi NUMBER
<br />TYPE
<br />BCEDENT'S
<br />IN
<br />NAME
<br />PERMANENT
<br />1
<br />BLACK INK
<br />SEX
<br />FOR
<br />INSTRUCTIONS
<br />7
<br />SEE
<br />Fq' LITY NAM. (ttno
<br />HANDBOOK
<br />STATE 'OF IOW4 "�`V
<br />0507869
<br />County Record 2 s 21
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH
<br />CERTIFICATE OF DEATH 114•
<br />FIRST MIDDLE LAST DATE OF PEAT14 fMo., Lay Yr.)
<br />Lan H Wan Chen 7 February 27, 2005
<br />AGE :LAST SIRTHOAV urNOaq 1 YEAR uNOER 1 DAY DAIS OF BIRTH (Me „Vey, YrJ COUNTY OF DEATH '
<br />fVeera)
<br />4a, 02 ab, ac, s M 8 ea.
<br />Mullion 91YO Street and number) CITY, TOWN, OR LOGATION OF DEATH INSIDE CI•iV LIMITS
<br />(Speclly yos or not
<br />e*
<br />Mercy Medical Center ac. Des Moines 6d: ss
<br />D ak-- --
<br />HOSPITAL ' F 01HER
<br />I a' n E A NulaM Hen. R r ,
<br />WAS DECEDENT OF HISPANIC ORIOIN7 RACE, WRile, Black, DEGEOEN TS EDUCATION cffy only h/ghasl gryde oomplefcd)
<br />eSnRoffy No or yes berpw) Amen— Indian, etc (Sperfl`y) emenlary ery - of ege
<br />- -. If yeq„,- SD/Ci(v an. McYlyn. Puerto RICan. eM✓ n ar
<br />m1ERE DECSnem T ND ES Sp -ory, a Korean 9 12
<br />RI*&SODE CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, $URv1v1NG SPOUSE(Irwile, he maiden
<br />lly?o, If OGTN lCMV6SUM OrFwe nCpunlry7 WIDOWED. DIVORCED(SPEf,)Fy) 9)
<br />occurmso inn LOxG. 10. 11 oath Karea 1ta
<br />TEAM tore Nenru SOCIAL SECURITY N FIBER USUAL OCCUPATION (Give kind of work done daring moat KIND OF BUSINESS OR INDUSTRY WA,S OECEDENT EVER IN us ARMED
<br />OF WORKING LIFE, Donal use retired,) 5ERVICE97 (SPef+YV a or no)
<br />TON, GIVE 19 327 - 76.8505 149. ti0R19Rlal(Df .
<br />10TIRITiTION rib wn Hg a 1s No
<br />NE$IOCNCE -STATE COUNTY CITT, TOWN OR I,pCAiION' ” STREET' AND NUMBER OF RESIDENCE'S INSIf1E CRY LIMITS
<br />RmREea aG
<br />!Sa I A .7s it 160 !.V'ieGN va9arno)
<br />8a
<br />FATNER'3 FIRST „ MIDDLE LAST MOTHER'S FIRST .MIDDLE MAIDEN
<br />NAME NAME
<br />17 9 unk
<br />INPORMANT'S MM1IL NG AV RE83(Street and Nunbefa Rawl Rolle) Number, CllY a TONNi,ljla(a, Zip Code)
<br />e' NAME
<br />192 vinds Chan 19b '.
<br />201 METHOD OF DISPOSITION PLACE OF DISPOSITION (Na— Of Cemelory, Cremafofy, LOCATION (City or Town, Slate)
<br />JR Burial i] Cremallon Q, Remb.r lmm8 pe PMhef play
<br />L7Donald- C7 Cther(Fpeerry)' m BronsvvgA emeter The. Oak Brook Illinois
<br />• ' FUNERAL HOME -NAME AN _ F.O. LICENSM.
<br />FUNERAL DIRECTOR - SignacIINI
<br />71a E! ■ t a Tovm,'Stete, ilp Codr
<br />�c�. �<' ' Pete Eicher
<br />D AObFtES3 (SuEel end Numhd w Rural Route NulTlb� CITY Ix e) 71b " - 2ti46... " "•. .
<br />ac Hamii I n 5 s Moi a 0
<br />. REGISTER .SIGNATURE'. DATE RECENED MAR REGIST FAR
<br />h Y.l
<br />• ZZ. ■ �• / rp Op_ iy A. G11 lam, ney, Yr) i1R 1 2UU5
<br />76 MANNER OF DEATH DATE OF fNJU HOUR OF INJURY 'IC, (INJURY AT. WORK? DESCRI,HER WIND Y GCUltR14RBp
<br />ImP.1My. rr.J I ePacay')sd One,
<br />Id Natural Cl Pending 44e 744 74C 74d
<br />Accident Investigation . C O 1 JURY(Specty In 4. Ism streal, LOCATION (Street and NwTfer mRual Rod1a -r, C %Ya eery.$lala, 7llpCade,
<br />[] Suicide [.']Could not be IW*% IssI outldn6, ep,),
<br />© Homicide dettemined 44 '
<br />To the heal of my knowledge; de th occurred at the b ,'d' and ace Is! he aua no menhef as stated IIUUR OF DEATH
<br />!'A (Slgnelme and
<br />NAM AN TITL HE ATTE G PH 81 N OT ANC T. R (Typ -
<br />26
<br />NAME AND ADDRESS OP CERTIFIER (Physl'cran or Medical ENarniner)(TypdPNnt)
<br />Tr Dr. Louise Hlav-in, 411 Laurel,. Ste. '#2350, Des Moines, TA '50314
<br />76 PART 1. Enter the diseases, Injurles, or corhplicatlona that caused the death. Do not enter the mode of dying such as Cardiac or respiratory arrest,
<br />shock, or heart m IIIBervedufe. 'List only one cause on each line. IAannalmele
<br />flENrEen
<br />Final desease ur wndltion !Dnbet and Deam
<br />resdengindemn� IMMEDIATE CAUSE
<br />ta) �1 �.re, YC.. t In +�rc� �- G_.. y�C r•1 -.o -'P �'u_,� .. � .�1^'7 ..
<br />$eQuarlgelly Ilse condition, If I DUE TO (OR AS A CONSEQUENCE OF)
<br />leading IC Immedlale Cause. Enter T (b)
<br />E UNFRLYING CAUSE (disease or DUE TO (QR AS A CCINSEOUENCE OF)
<br />injury Ihal lnilisled events roEUlting (C)
<br />In death) LAST.' )
<br />(d)
<br />'PART II,a. Qlher elenllltln)„pondi JM contributing to death but Iwl resvnin in the b• IF FEMALE WAS THERF.A AUTOPSY WERE AUIOPSV FIND-
<br />. undelrylRy Causes 91VEP IRPMI. IPRFONANL'Y IN THE PMT 12 ($pec"yra -nof INIi$ AVAILABLE YHIUR -
<br />IMUNI'HS7 TO UCWPLET16N OF
<br />i(SPECKY Yea ane)
<br />CFN•58B -06TI �k,4rty /) q� /� CAUSE OF DEATH?
<br />Reylxd 1169 ! ' — o (Spodyyes OF no)
<br />(tS) 20050293 i96. 29b.
<br />This is to certify that this is a true and correct reproduction of the original record as recorded
<br />,?W \11111,U 14 r \ \ \ \!� \1gy1�1�1j11
<br />U in this office, issued under authority of Chapter 144, Code oflowa.
<br />t OF TFjE4��t(J REGISp�
<br />MAR 15 2005 sY r t OF FOLK—
<br />IOWA
<br />_ DATE ISSUED COUNTY REGIST AJW VITAL RECD COUNTY m
<br />C1 936381
<br />TO DUPLICATE TWIS CC)PY
<br />�'.
<br />!1� ..FORMx588.0328C(1999).., WARNING: IT I$ (I.,h�G141,.... .. -..._ _......... - _ h'
<br />
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