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Kansas Departmentot.Healthand.Environment Office of Vita I Statistics CERTIFICATE OF DEATH 200607081 AMENDED - 04/21/2006 115-2006-07137 1. Decedent's Legal Name (First. Middle, Last) State File Number 4. Social Security Number 5. Date Filed I\v State Registrar JOHANNA JANE LOGAN Ga. Date Of Birth (Month, Day, Year) 6b. Age 7; Place.Of Blflh(CityAnd Stilte Or Foreign.Country) 506-58-9530 04/21/2006 8. Decedent Ever In U.S. Armed Forces 12/02/1945 60 YEAR(S) 9a. Place Of Death KEARNEY,NEBRASKA 9b. Fadlity Name (If Not Institution, Street And Number) NO DOUGLAS MARRIED 9c. City Or Town Of Death 9d. Zip Code DECEDENT RESIDENCE ge. County Of Death LAWRENCE 66049 10. Marital Status 11. surviving Spouse (If Wife, Name Before First Marriage) 12a. ResJdence Slllte or Foreign Country 12c. City Or Town WILLIAM SLOGAN 12d. Street Address KANSAS 12b. County or Province 12e. Zip Code Uf. Inside City Umits DOUGLAS LAWRENCE 1424 BRIGHTON CIRCLE APT D 14. Decedent's Race 66049 YES 13. Decedent's Ancestry AMERICAN 18. Decedent's Industry 15. Decedent's Hispanic Origin NOT SPANISH HISPANIC LATINO 16. Decedent's Education 17. Decedent's Occupation MASTER'S DEGREE 19. Father's Name (First, Middle, Last) SOCIAL WORKER MEDICAL HOSPITAL 20. Mother's Name Prio~ To First Mamage (First, Middle, Last) WILLIAM SLOGAN MURIEL 21b. Mailing Address (Street, Number,Oty, State,And Zip Code) 21e. Relationship To Decedent GEORGE STALKER 21a. Info~mant's Name (First, Middle, Last) 22. Method Of Disposition 1424 BRIGHTON CIRCLE APTD LAWRENCE, KANSAS, 66049 HUSBAND 23il. Place Of Disposition 23b. Locatlon REMOVAL FROM STATE GRANDISLAND,NEBRASKA 2s.Name Of Embalmer And Ucense Numbe~ 24. funeral Service Licensee And Ucense Numbe~ Is/ LARY K DODGE - 2503 MELANIE A BEAMAN - 3599 26. Name And Address Of firm PENWELL-GABEL MIDTOWN CHAPEL, 1321 W 10TH, TOPEKA, KANSAS, 66604 27. cause Of Death Part L Events (diseases, injuries, o~ complications) that di~ectJy caused the death. Approximate Interval: Onset To Death IMMEDIATE CAUSE (Final Disease O~ Condition Resulting In Death) a. SEVERE CORONARY ATHEROSCLEROSIS Due To (O~As A Consequence Of): b. Conditions, if any, leading Due To (Or As A Consequence Of): To cause listed on line a. c. UNDERL YlNG CAUSE (disease Due To (Or As A Consequence Of): o~ inju~ that Initiated the d. events resulting in death) Due To (O~ AS A Consequence Of): USTED LAST Part II. othe, Significant Conditions Contributing To De2th But Not Resulting In Tr'" Underlyin\lCiluStiGivenln Part I. 29. Did Tobacco Use Contribute To Death? 30. If Female: -J HYPERTENSION 28b. Autopsy findings Available :l8c. Coroner Contacted To Complete The cause Of Death YES YES YES NOT PREGNANT WITHIN THE PAST YEAR NATURAL 32a. Date Of Inju~ (Month, Day, Year) 32e. Place Of Inju~ 04/13/2006 J4a. Pronouncing and Certifying Physician 2130 UNKNOWN JASON WILLIAMS 34d. Address And Zip Code Of Person Completing Cause Of Death jili. License NQ. ~- 33a. Date Pronounced Dead (Month, Day, Year) 3310. Actual Or Presumed Time Of Death 34b. License No. IS/ERIK K MITCHELL - MD 425034 3205 KANSAS STE #400, TOPEKA, KANSAS, 66603 VS231A - Rev. 06/18/2004 DEATH 4/21/2006 T2100039636 01 LOGAN 200604007137 12c @@Courier @@