|
<br />'"
<br />e
<br />e
<br />-....J
<br />e
<br />(0
<br />-->.
<br />en
<br />'"
<br />
<br />'J
<br />
<br />C\:;~
<br />~ )..) "'\
<br />~ -C (to
<br />~ :t:.
<br />
<br />~~'E~
<br />~ $I _)
<br />f0 ~ ~ ~
<br />W M- s::...
<br />~ (" e:.
<br />IT\ ~
<br />ur'"/I, IS7Jt[ /< /:1, IJ tff S tf~::1)'(II;; /f /)(A->> L'~;~('.// /c
<br />-1/1 t? (/~'/1 Cf i<"Yc)/J eJ ._;-5)4'7/[/ i'):E
<br />200709162
<br />
<br />STATE OF TEXAS
<br />I. PL4CE OF DEATH
<br />.. COUNTY
<br />
<br />HARRIS
<br />
<br />b. U TY OR TOWN (II ouhid. city li"';h, givo p'oeinel no.I
<br />
<br />HOUSTON
<br />
<br />'n
<br />'%:
<br />m
<br />n
<br />;"I;
<br />
<br />10
<br />m
<br />C!
<br />Z
<br />~~
<br />C/)
<br />::J:
<br />
<br />nn
<br />:J:>
<br />m C/)
<br />n:E:
<br />'"
<br />
<br />~~-"
<br />c...).
<br />c.-:;>
<br />--.2
<br />
<br />I
<br />Gr
<br />I
<br />i
<br />~
<br />
<br />(')) (/)
<br />01,""--1
<br />c::>
<br />% "'-'j
<br />_~ m
<br />-<0
<br />0""'"
<br />""'lZ
<br />::J: rf1
<br />1> en
<br />r ?J
<br />r- ]:..
<br />ell
<br />;;:><:
<br />po.
<br />--
<br />
<br />\'::)
<br />rv
<br />o
<br />c::::>
<br />-..J
<br />o
<br />CD
<br />........
<br />0)
<br />N
<br />
<br />';:::t:\..
<br />~ ~:'
<br />
<br />c)'<~
<br />'""1
<br />
<br />C::l
<br />7J
<br />---i
<br />
<br />N
<br />0)
<br />
<br />U\.
<br />
<br />h
<br />~.
<br />~
<br />
<br />liU
<br />".,
<br />nl
<br /><';;J
<br />r..n
<br />
<br />::D
<br />::3
<br />~....
<br />o
<br />N
<br />cn
<br />
<br />en
<br />(f)
<br />
<br />\j\
<br />()
<br />
<br />r'~
<br />v'.JCJ
<br />
<br />~
<br />
<br />CERTIFICATE OF DEATH
<br />
<br />STATE FILE NO.
<br />
<br />c. LENGTH OF STAY
<br />in 1 b.
<br />
<br />2_ USUAL RESIDENCE IWhel'"8 d@c$tUll;ld lived. If ill5titutiQn; reo;id$m;e before .,dmis,sionl
<br />o.STATE LOUISIANA bC:JU~~to Mary
<br />
<br />"':. CITY OR fOWN {If outsid~ city limih, give precind no,l
<br />
<br />MORGAN CITY
<br />
<br />d. NAME OF {II n-;;I in ho,pilol. givo oI",olodd",..1
<br />HOSPITAL OR
<br />INSTITUTION VETERANS .ADMINISTRATION HOSPITAL
<br />0.15 PLACE OF OEATH INSIOE CITY LIMITS?
<br />
<br />U
<br />5i
<br />;:;
<br />~ 3. NAME OF
<br />..J DECEASED
<br />:; IT ypo 0' pr;nl!
<br />'> S. SEX
<br />
<br />YES !:X
<br />
<br />(0) Fi"t
<br />
<br />d. STREET ADDRESS (II 'u,.I, gi"ol"".tioo)
<br />
<br />General Delivery
<br />.. IS RESIDENCE INSIDE CITY LIMITS?
<br />
<br />I LIS RESIDENCE ON A f"RM?
<br />. YES D "'-'Xl
<br />
<br />NOD
<br />(b) Middl.
<br />
<br />YEsK! NO D
<br />(<11...1 ~I.' DATE OF DEATH
<br />
<br />BY, lilL 19, U7a..-_, r
<br />i.a, OME Of BIRTH 19. ~~ti~h~:~' Li:J~~~DERI'6~y~~~R lif~~:;Dt~I'. ~;~l:::'
<br />lMAY 24. 1928 49. ____
<br />ill. BIRTHPL"CE ISt.t. 0' 10'0;90 eount'yl 1'12. ClIIZEN 01 WHAT COUNTRY'
<br />Garrison, Texas U~~A.
<br />I.. MOTHER'S M"IOtN NAME
<br />
<br />B
<br />
<br />(;
<br />
<br />MALE
<br />
<br />
<br />Never Mluried 0
<br />Divorced
<br />
<br />CondHions., if ""y.
<br />which gav~ ri!ie to
<br />.bo". cou.o 101,
<br />do!ltinq the ul"lder.
<br />lying ~"U'ie IlIst.
<br />
<br />}
<br />
<br />DUE TO (bl CIRRHOSIS
<br />
<br />Shipping
<br />
<br />i Leona Fergerson
<br />/17. INFORMANT
<br />! $teve Broadway
<br />
<br />( Son )
<br />
<br />Sam Bass Broadway
<br />1~,_':^'~LQ..~~~~tL~~~~._I!,! u.s. ARMED i9!.<;;~~.\ lb. SOCIAL SECURITY NO.
<br />{Y $$, no, or U"~"ow"l 1 (If yes, give wet or dates. of 5ervice)
<br />~ Y , 1- - 463-36-7996
<br />;to 18, C"USE Of DEATH [Enl., enly en. cou,. p.r lin. fo, 1.1, Ibl, ond (c).]
<br />~I PART I. DEATH WAS CAUSED BY,
<br />~ IMMEDIATE CAUSE 10J HEPATORENAL SYNDROME ANn HF.PATH~ r:OMA
<br />...
<br />z
<br />'"
<br />~
<br />0::
<br />:
<br />'"
<br />o
<br />'"
<br /><(
<br />><
<br />'"
<br />t-
<br />
<br />'NT~~\i,""i, !P'j\i~~~
<br />'-.'N~P ....j" !' f....TI1
<br />
<br />L
<br />I
<br />I
<br />I
<br />I
<br />
<br />DUE TO 1<1 NO~T lIKELY ALCOROL
<br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT' NOT RELATED TO THE TlRMINAL DISeASe CONDITION GIVEN IN P"RT 1('1
<br />
<br />z
<br />o
<br />~
<br />\,)
<br />j!; 20...
<br />'"
<br />o
<br />
<br />5 20<.
<br />15
<br />'"
<br />:I
<br />
<br />"CClDENT
<br />D
<br />
<br />SUICIDE
<br />D
<br />
<br />HOMICIDE
<br />D
<br />
<br />TIME Of
<br />INJURY
<br />
<br />H"",
<br />
<br />Monlh
<br />
<br />Doy
<br />
<br />Ye~r
<br />
<br />!!I.m.
<br />
<br />20.. PLACE OF INJURY lo.g.. in 0' oboul horn., I.rm.locle'y, 201. CITY. TOWN. OR lOCATION
<br />$tn;t~", office blllldi"g. ~tc.)
<br />
<br />5T A TE
<br />
<br />p.m.
<br />2Od. INJURY OCCURRED
<br />
<br />STATE OF TEXAS
<br />COUNTY OF HARRIS
<br />
<br />~~~: AT 0 ~~'w~~~t~ 0
<br />21. ,I.
<br />I h.,.b" ,.,tily Iho,' VA"dod tho d""..,.d 1'0,"
<br />" AEB.IL~I:-- r D..,h occur,.d 01
<br />22.. SIGNATURE FJ' V~(.t:) ~ (D.g'o.ort~
<br />G. DOUGLAS CAIN M:'n " , 4')1 , r/;J .
<br />2)0. BlJRI"l" CREMATION, REMOVAL(Spoc;ly) IVb. DATE
<br />~ Burial ~pri1 2,. 1978
<br />- 13d. LOCATION --ioiY:t;;-;;;;;~;;;;lyf--'- - ii;I~;~j-"----'
<br />
<br />~ Houston, Texas
<br />N 250. REGISTR"R'S FILE NO. I 25b. DATE REC'D BY LOCAL REGISTRAR
<br />
<br />~ - 65 Ara~ -&.8..-1916
<br />
<br />I HEREBY CERTIFY THAT THE ABOVE IS AN EXACT COpy OF ACERTIFI~TE AS FILED
<br />IN THE BUREAU OF VITAL STATISTICS, CITY OF HOUSTON HEALTHpEPARTMENT,
<br />HOUSTON, TEXAS, AND THAT I AM THE LEGAL CUSTQPI~,~~~.~J:I,RECORDS.
<br />I ~ \J. .11 II" oil ..., " ,I
<br />\ ", '.-'\..~rA'" ',: I
<br />,,"'-"'~'...." ,." ",'. . "
<br />'''"",, J~ :".1 . '. . .,... 't'.' ',' .; ,
<br />...\,,11,;:. ,,' i.~,;",:~:, '" .1 ~, ,:', \, ~ "I"1lJ "l~. ,l~ I
<br />'.. i,\i5.::~,.~. . ......,V.Ii.. .... .'ce ''';~,1'-v ~... J
<br />.. 'v.. ,~,'~I I ,,~,,""'l., ~~ ;'
<br />" c...~I~~~' \ ,.."" . '. . 4 I
<br />>. f.Ul":'ill:...". ;.~:.., >~!,,\:. ~. .elt:. .-'. .f.'
<br />'.,"" ... I .. ~ · , !.
<br />. ,,' "II''' - ~"" . "
<br />'..". 0"', . I. ,. ':11',"
<br />". ...... "J.-" \ i. "i'. ''1;'''''',
<br />", Ii. ra- ~il!
<br />HiJ: If,. "'GAdR '" .~ STRAR
<br />BUn(~l6;OlQt~:."ST A TIS1ICS
<br />\\\\\;.\.,....,~~~....
<br />
<br />...
<br />
<br />I
<br />1
<br />IIQ. W"S AUTOPSY PeR
<br />I fORMlI)!
<br />Yr~~.~r:x
<br />
<br />120b.
<br />
<br />
<br />i
<br />
<br />DESCRIBE HOW INJURY OCCURRED. lEnt., nolu,. 01 ;niu'Y in P.rt I 0' PorI II ef It.m I a.1
<br />
<br />COUNTY
<br />
<br />APRIL 5
<br />
<br />
<br />..
<br />
<br />. IOZA....
<br />
<br />~f1d IL~d ~~w ,1.,- j~,,,:,,,:,:;,, ~Jd \1;..'.
<br />
<br />h'L on HlII!I dt!lotB !t!!ted ~bol,le, ~nd to the bed of my ~1'!~',;"':,'~,d9~. 'rC1t"1'1 ~\.~ ..-,~\He\, '.t,~~
<br />nt.. OA TF SIGNf.(J
<br />!
<br />I 1y,,~^~Oo':~~']i~ofp.H,'irg~_lc-25tia _ .
<br />to::~:~o~~~!~lrl:::et~th:f8J4
<br />,.~~~ ~---~=-"=--
<br />
<br />r~ ._
<br />
<br />. -- - . -~_. ,~- ,,_.'----~-"",--,_.......-.,~~
<br />
<br />CITY OF HOUSTON
<br />BUREAU OF VITAL STATISTICS
<br />
<br />(WARNINGl NOT VALID UNLESS MACIlINE SIGNED IN RED AND BLACK INK.
<br />AND THE RAISED SEAl. OF THIS OFFJeE AFFIXED HERETOl
<br />
<br />DATE ISSUED
<br />
<br />May 1,
<br />
<br />1978
<br />
<br />. -
<br />
<br />'a__.
<br />
<br />.. _.~_"'__''''_~'''''''':''''J..,~...-.-...,ilo::~:ir':l~f~~.:}:t''a~~~~:'':;;:.~ ,~" '<'(",~"~"'''~'
<br />
|