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STATE OF IOWA
<br />County Record 200314990
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH 114-
<br />BIRTH NUMBER CERTIFICATE OF DEATH
<br />TYPE Mini F LAST I DATE OF DEATH(Mo., Day, Yr)
<br />BLACK KT
<br />W
<br />'Ante
<br />Dannie Stauffer
<br />2. Ma 2_2003
<br />FO R
<br />NETRUCTIONB
<br />SEX
<br />AGE -LAST BIRTHDAY
<br />UNDER I YEAR
<br />UNDER I DAY
<br />DATE OF BIRTH(Mo., Day, Yr.)
<br />COUNTY OF DEATH
<br />NArseBe
<br />J.Male
<br />(� ') 80
<br />MbOS. DAVE
<br />A. S IN
<br />s.A r 26, 1923
<br />I ee.Polk
<br />FACILITY NAME (If not insigubh .9i' street and number)
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />m C LIMITS
<br />2Ae.
<br />eb. Bickford Cottage
<br />sc. Urbandale ltW.
<br />Y
<br />LACE O FATH (GnecA on/ one
<br />❑ Suieide ❑ not be
<br />HOSPITAL OTHER
<br />❑ ahem ❑Ewout abenl ❑ DOA ❑ Nursing Homo ❑ Re.idence ®ahem s Assisted L1 vino
<br />MWAIM
<br />WAS DECEDENT OF HISPANIC ORIGIN?
<br />RACE K White. Black
<br />DECEDENT'S EDUCATION (Sperry only
<br />highad grade twnplefed)
<br />( Specsy Ab,or Yes below)
<br />(Specify)
<br />EbmemarylSecondary (0-12)
<br />College (i-1 or 5.)
<br />K yes, Warily Cuban, Mexican, Puerto Rican, etc
<br />1&wlTlte
<br />,f
<br />iENCET''EMERE
<br />® NO ❑ YES sped :
<br />9.
<br />2
<br />JECEOENt
<br />CITIZEN OF WHAT COUNTRY MARRIED,
<br />NEVER MARRIED, SURVIVING
<br />SPOUSE (if wife, give maiden vane)
<br />_aW. IF MAT
<br />xtrutREB el A
<br />�oao-TeRM
<br />y 6 State or Foreign Country)
<br />t!BIRTHPLACE
<br />Pa e, NE
<br />WIDOWED,
<br />++.U. S.A. 12..Married
<br />DIVORCED (Specify)
<br />- 12b.
<br />Doris Dworak
<br />c— INerITU-
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION (Give kmda wrfr Ic dune daingm�sl KMDOF
<br />"—
<br />BUSINESS OR INDUSTRY
<br />WAS DECEDENT EVER M U.S. ARMED
<br />SERVICES? ( Specfy or no)
<br />NSTITUIYE
<br />N9TITUNON
<br />of wIdng lde. Do louse retired.)
<br />yes
<br />No
<br />aooaESS AS
<br />1x.508 -22 -1929
<br />++a.Re tu•Real
<br />E
<br />u.
<br />9E910ENCE
<br />RESIDENCE - STATE COUNTY CITY, TOWN, OR LOCATION STREET
<br />AND NUMBER OF RESIDENCE
<br />NBIOE Cm LBAITS
<br />speoTy yea or m)
<br />is.. INIF isb,Nall 116-.f:,:: and cA anc: Tpd.32
<br />7 Pheas -int Drive
<br />Ill.. NC
<br />ATHER'S FIRST MIDDLE LAST
<br />MOTHER'S FIRST MIDDLE MAIDEN
<br />NAME
<br />17.Daniei Stauffer
<br />NAME
<br />1i Achsah Ames
<br />INFORMANT'S
<br />MAILING ADDRESS '(Street ad mba ar Rural Route Number, City or Town, Slate, Zip Code)
<br />NAME
<br />19• Doris'Stauffer
<br />+1b -327 Pheasant Drive Grand Island HE 68801
<br />METHOD OF DISPOSITION
<br />PLACE OF DISPOSITION (Na— or Cemetery, Crematory,
<br />LOCATION (City., Town, Slate)
<br />20e
<br />�-t
<br />® Burial ❑ Cremation ❑ RWOYBI I— Stale
<br />a other 011)
<br />E] Don ❑Omer{
<br />zab. Elm Creek Cemeter
<br />20o.Elm Creek, NE -
<br />FUNERAL DIRECTOR - SIDN
<br />F.D. LICENSE*
<br />21. 1"
<br />21b. 2272
<br />IFUNERAL HOME - NANrJ: µ1J ANUnca. (weer ana oar a wrai r.ww , ^
<br />REGISTER - SIGNATURE
<br />>]
<br />DATE RECENED BY REOIeTRAR
<br />(Aio., Day. Yr.)
<br />22. 1
<br />f&
<br />22b.
<br />MANNER OF DEATH
<br />DATE OF')
<br />INJURY AT WORK?
<br />DESCRIBE HOW INJURY OCCURRED
<br />(MO, filly, Yr.
<br />-
<br />(Speedy yes or no)
<br />,,,......)))
<br />atural ❑ Penceig
<br />2" -
<br />Ztb. M:
<br />2Ae.
<br />24CL
<br />Ac z:rt inv"tlgelwa!
<br />PLACE Of INJURY (Spacrry N hams. lsEn sbeal
<br />LOCATION! ISWW and Numbei W Rural Route Number, City or Town, State, Zip Code)
<br />❑ Suieide ❑ not be
<br />fW ry, of— b1�rg, at.
<br />determined
<br />❑ Homicide deter
<br />To the best el my knowledas, dasAScecurrod al the tines delb ado/o/11a��e//eeae��dueMtina
<br />Iti and In— un staled.
<br />flf.Ab D (Mo., Day. Yr)
<br />HGUR OF DEATH
<br />,f
<br />25a. (Signature and title)
<br />-
<br />25.
<br />NAME AND TITLE OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (T
<br />rk8)
<br />NAME AND ADDRESS OF CERTIFIER (Physician or Medical E,omN r)(TypeiPrint)
<br />� 2T.
<br />Dr. Darrel Devick, 717 Lyon Street, Des Moines, IA 50309
<br />l
<br />22. PART 1. Enter the diseames, Ngur . or complitslmi s, gal caused the ouglfs.'Do trot War the Tolle of ay9g, such 85 caaec of resplratpry anent, I� BeFaeen
<br />.hock, or hurt Wk". List omy ma cause on each line.
<br />Onset and Death
<br />n
<br />Final disease or condititm � IMMEDIATE CAUSE
<br />resulting in death
<br />(a, Pit
<br />DUE TO (OR AS A CONSEQ NCE OF):
<br />Se4o•niblly fiat ccxhtli"c w, H any, f eta YV� J� (,t {'AIO U/ A/
<br />leading to immediate cause. ErNa (b)
<br />UNDERLYING CAUSE (Disease a DUE TO (OR AS A CONSEQUENCE OF):
<br />inµxy that initiated ..."u reaulang (c)
<br />in death) LAST DUE TO (OR AS A CONSEQUENCE OF):
<br />PART I1.a. OI r significam conditions con lritxAirg to death but not rasullkg In the
<br />u rr--��ymg causes 9rren m Pant(/II y-
<br />CFN- 588 -0021 )��S I ✓I��-�rN 1 �I' u 1
<br />Revised - 1189
<br />(TS)
<br />b. IF FEMALE, WAS THERE A AUTOPSY WERE AUTOPSY FIND -
<br />PREGNANC'iIN THE PAST I2 (spaciy yes or no) INSAVA— EMI OR
<br />MONTHS? TO COMPLETION OF
<br />(Specify yes Or no) CAUSE OF MATNi
<br />(Spenly yes or rte)
<br />29.. No 29b.
<br />This is to certify that this is a true and correct reproduction of the original record as recorded
<br />in this office, issued under authority of Chapter 144, Code of Iowa. \
<br />MAY 13 2003 BY OF POLK
<br />DATE ISSUED COUNTY REGIST F VITAL RECORDS COUNTY
<br />C1423679
<br />FORM 8588 -0328C(1999) WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY
<br />p= IOWA
<br />c '
<br />As�99lrON •OF VIt P�-S�P 1,,;
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