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<br />ON OTHER SIDE
<br />
<br />200707731
<br />
<br />BIRTH CERTIFICAtE NUMSER
<br />
<br />CERTIFICATE OF DEATH
<br />
<br />ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES
<br />BUREAU OF VITAL STATISTICS-P'Q BOX 110875
<br />JUNEAU, ALASKA 99811-0675
<br />
<br />150
<br />
<br />STAtE "ILIS NUMBeR
<br />
<br />RECDRDeR'S No'
<br />
<br />
<br />00-53
<br />
<br />1. ECECENrs NAMe (FI"" Ail"",,, La.t)
<br />
<br />'" ~AIDeH NAME
<br />
<br />Merle
<br />4, IAl. U TV NUMBER
<br />
<br />1 1r1"'dl';'
<br />
<br />07-08-00
<br />7.8IRTHPlACE
<br />fara holgl1 CoufltM
<br />
<br />,..
<br />(YrJIJf8)
<br />
<br />507-32-8449
<br />
<br />69
<br />
<br />AN
<br />A LAS KA NOSPITA" 0 Inpa"enl 0 ERIOuI"",'enl
<br />gb, FACILITY NAME (If not Ir't~tltutlo,.,. (JiNl :Ul'Ht ,na nurnN"
<br />
<br />Ketchikan Harbor
<br />
<br />9a. PLACE OF DEATH (Ch-.ck OM; ... In.tn.x:U",.. 011 o,,,.,..Jde,
<br />HER-
<br />oDOA . o NUrotngN.... 0__ []Ot....I_II)1
<br />Ik:. CITY. TOWN, OR l..QCATlON Of DEATH
<br />
<br />Ketchikan, Alaska
<br />11. SURVIVING $POU$E (It 1M'" QIWJ "...",....,
<br />
<br />DUNKNOWN Darlene Morse
<br />
<br />12b. KIND OF BUSINES$IINDUSTRV 13. WAS DK:EDENT EVE" IN u.s. ARueo FORCES?
<br />
<br />Harbor
<br />
<br />10. MARITAL $ ATUS
<br />
<br />o NEveft M...ARII~.D CXMARRIED 0 WIDOWED 0 DIVORCED
<br />1 .. oe . USUAL OCOUPATION (Give kind of walk done during molll af
<br />working life. 00 M' UN ",'lmdJ
<br />Drywall
<br />14.. e STATE 14b. CITY, TOWN OR LOCATION
<br />
<br />Construction U yes oNO DUNKNOWN
<br />14c. STREET AND NUMBER
<br />
<br />
<br />4204 Springview Dr.
<br />
<br />Grand Island
<br />
<br />
<br />14d. IN I I LIMITS OR
<br />SETTI.ED COMMUNITY?
<br />
<br />,.... ZIP CODE
<br />
<br />15. WAS OECEDENT OF HISPANIC ORIGIN?
<br />(SptJeJfy NO or v",-If YH, '""'fy cuo.n,
<br />Uo't:8IJ, Puef1tJ if/eM. flft;.J
<br />
<br />11, RACE AIt~no. Bla.::k.
<br />N.I.,., WIll.... eIc,
<br />
<br />11.
<br />
<br />!Xl YES 0 NO D UNKNOWN 6 8 8 0 3
<br />NAME (Flm', Middle, LOI)
<br />
<br />tJ NO, DYES $_il",
<br />
<br />S_''''' whi te
<br />18, M HER"! NAM (PI,."".I<<IM,.....,. ~
<br />
<br />Hugh Stewart
<br />20.. INFOR~"N '$ NAME (TyplillPrlnt,
<br />
<br />Jane Schoonover
<br />2Ob. MAILING ADDRESS (Stlft,and NumberorRu'" ROIl" Numo.r, tyo, n, StaM, ZIp CocMi; 8803 .2OG- REL4.TIONSHIPlO DECED Nl
<br />4204 Springview Dr.Grand Island,NE Wife
<br />210. LACE OF DISPOSITION (NaiM 0' c"",'.,y, r;~ or Qf. pi...} .tic. l..OCATION CUy or Town, St...
<br />
<br />Stewart
<br />o DISPOSITION
<br />
<br />Central Nebraska Crematory
<br />
<br />Gibbon, Nebraska
<br />
<br />N ACTING A$ $U H
<br />
<br />22b. NAME. AND ADDRESS OF FACIUTY
<br />
<br />P.o. Box 8181
<br />Ketchikan, AK
<br />
<br />99901
<br />
<br />Ron Randall Ketchikan Mortuary
<br />2:3a. To the belli ot my knowlttdgll,. d..lh occurT8d al the limit" dat.. iUtd pi... .tatH.
<br />
<br />:23b. DATE SIGNED
<br />(""OIIln,o..-; ,..."
<br />
<br />SIr/llaIU", alld rme.
<br />
<br />2.. TIME OF DEATH
<br />
<br />25. DA P NOUNC OS,A. (MoM", O~ YaI1
<br />
<br />28.. WA$ CASE REFERRED 10 MEDICAl. SXAMINERlCORONER?
<br />
<br />1353
<br />
<br />Q-
<br />
<br />oNO
<br />
<br />M
<br />
<br />07-08-00
<br />
<br />27, PART I, Entillr tn. <:1I.......II"Ilun.., 0' c:ompllc::.lIonllh" c::.-u-.d the d.ath. Do no' ,nt., th. mQCi. of dying. auch _ cantlac Dr rM~AIIoIy....... Mocl(, or hNn f.Uu...
<br />1.11' only one call.. on e~h Una
<br />
<br />Probable complications of arterioscloerotic cardiovascula
<br />
<br />DUE TO (OR AS A CONSEQUENCE DF), d i sea s e
<br />
<br />ApprOJl:lmlrl Int.rvaI
<br />Bet~ On... " o...h
<br />
<br />IMMEDIATE CAUSE (FII't"
<br />dl...... Of c:ondlHon
<br />'-Iultlng In d..ln)
<br />
<br />s.,ql,lentlally Uat condltlona. If
<br />IIny. le.dlng to Imm.dlat. 0.,....
<br />ISnt., UNDERI.YING CAU$E
<br />(dllU:l'De 0' InJl,lry thm Initiated
<br />eventa rwaultlng in dMtn) I.AST
<br />
<br />DUE TO (OR AS A CONSEQUENCE OF)=
<br />
<br />DUE 10 (OR AS A CONSEQUENCE OF):
<br />
<br />.
<br />:A. SIGNIFICANT CONDITIONS eOl'ltr'lbuth'liIlo d...,.. but 1'101 ,....uIUr,CjIln It't. uPG.l1ylng GluM gl~n In ~ I.
<br />
<br />__ WAS AN AUTOPSY
<br />PERFoflUEO?
<br />
<br />2Ib. WERe AlIfOP$"f FINDINGS
<br />CONSIDeRED PRIOR TO
<br />COMPLETION 0': ~SE
<br />of DEA1'l<'
<br />
<br />DYee oNO
<br />
<br />0_ IJNo
<br />
<br />29a. CERTIFIEA
<br />(ChltCk only on.)
<br />
<br />OF" D~TH- 18 OTHiliA THAN .o;L"4.."Qt~\ \-r .... ~. . ::nt MU..... ee COMPLIlETI!D.
<br />31c. IN.,lURY AT WO:~K1" 314. ~~.ee ... IfURY OCCURRED? (&Mr. WIIIt;1I ,...p.'lllnJury)
<br />
<br />DV........"t:.JNO. .".., I~,
<br />:31& PlACE OF INUAY~At hom.. IIt,"i, cann.". otfIc.. .te.. (~ , .. " 31'. ~T10Nt$~ and NtArfMoI Au'" AouW Number, City ar Town, Stm.)
<br />
<br />",iii ."11 I,,;
<br />
<br />3a. R~CORDINC2 &Im>."Cf . ....
<br />. Fi.r!l.,t"'. ;, ~ 7/19/00
<br />
<br />: : - 61 ,-~..~,;.--.ltwieby d&nily tnai ttle ilMeXtO InI1nJfnent 18
<br />ORIGINAL'., ~!~!E CPY, a !^-,qOOfYeet c:opy of the origin&l on file In
<br />"; ftfob. 12~ ~
<br />.....~..,...."AlJ:EST[& ~~i ;;/00
<br />"1., .-'" -TRIAL UATS
<br />" '\, \,,, ',', .," StateofA/lnlka
<br />at KiItChlkan
<br />
<br />;
<br />
<br />34-. DATE Flt...eO (""""h. 0.,. )tgrl
<br />
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