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<br />1. AECEASEp--NAME First Middle Last (Type last name all capitals) 2. DATE OF DEATH IMonth, Day, Yearl 3. COUNTY OF pEATH
<br />Lola Irene OSTBERG June 11, 2010 Baldwin
<br />0.. CITY, TOWN, OA LOCATION OF DEATH AND ZIP CODE 5. INSIDE CITY LIMITS 6.PLACE OFDEATH-HOSPITAL OA OTHER INSFITUTION~H not in either, give street and number)
<br />Spanish ForC, 36527 IY~w"°I Westminster Village
<br />T. tF HOSPITAL jSpecHy Inpatient, ER or Outpatient, DOAI 8.OF HIS
<br />PANIC ORIGIN ISpecity Yes a No) N Yes, Specity Cuban, 9. RACE~Specity American Indian, Black, White, atc.1 10. SEX
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<br />~u, Puerto Rlcen, etc.
<br />u Whlte Female
<br />11. AGE 12. UNDER 1 YEAR UNDER 1 DAY
<br />13. DATE OF BIRTH (Month, Day, Year) 14. DECEASED'S SOCIAL SECURITY NUMBER
<br />95 rRS. Mos, oars HDURS MINS. April 13, 1915 505-07-5231
<br />1 . ED TI s i N Y ni h 16. MARITAL STrA~TCUS~I5pecity Married, Never Married, 1 T. SURVIVING SPOUSE 1N wde, give maiden name) 1 B. Was Oecedem ever in Fumed
<br />Elementary or High 5clwol 10.121 C°Itege (t-4 or 5tl ~~ r j,d Fpecity Yes or Nol
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<br />19. STATE OF BIRTH IN not i
<br />n USA, name country) 20. RESIpENCE--STATE 21. COUNTY 22. CITY, TOWN, OR LOCATION ANO 21P CODE
<br />South Dakota Alabama Baldwin Spanish Fort 36527
<br />23.INSI~ECITYLIMITS
<br />~YesarNo) 24.STREETANDNUMBEA
<br />0 25.INFOAMANT-Name and Address O art St erg
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<br />0 Spanish Fort Boulevard ropwell, AL 35054
<br />110 Treasure Island Circle,
<br />28. USUAL OCCUPATION 1Give kiM of work done during most of working life even if retired) 21. KIND OF BUSINESS OA INDUSTRY
<br />Homemaker Own Home
<br />28. FATHER-NAME Firer Middle Lest 29. MAIDEN NAME OFMOTHER- First Middle Last
<br />Burris V. Nicodemus Helen E. Harkens
<br />30. DISPOSITION pF BODY 15peciN Burial, Cremation, Medical
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<br />(( 31. DATE OF DI5PDSITION
<br />M 32. CEMETERY OA CREMATORY-Name 33.LOCATION-1Ciry or Tnwn--State)
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<br />^ Wolfe-Bayview Fairhope, Alabama
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<br />34. FUNERAL HOME-Name and Address a Cley UneTa OIT1e
<br />and Address a nay une
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<br />Ome 35, TUNER RECTO -5 nature
<br />35, TUNER RECTO -S nature 36. DATE SIGNED 6Y FUNERAL DIAECTOR
<br />36. DATE SIGNED BY FUNERAL DIRECTOR
<br />P.O. ox 7245, Mobile Alabama 36670 June 29 2010
<br />3T. Certifying Physician (Physician certityi f tleathl'?o the best of my knowledge death occurred the time and date, and . e to the taus s1 and manner stated." 38. DATE SIGNED (Month,
<br /> pay, Yearl
<br />_ Medical Examiner _ Coro r "On the basis d aNVa imestigetion, in my opinion, death occurred at the time, date, place, and due to the causeisj
<br />and manner st~tao. ~ ~ / ~7 _ ~~
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<br />Signature:
<br />39. TIME AND DATE OF DEATH 40. DATE. E PRONOUNCED DEAD (For Coroner/M,E. use only) 41 NAME AND TITLE OF PERSON WHD COMPLETED CAUSE OF DEATH (item 461
<br />~- ~25~ , Vl,~~,.t avids~lh..
<br />4 . ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH pram 46) 43. CERTIFIER LICENSE NUMBER
<br />~ ~ ~e A~ 3(o53Z /$ Gl'
<br />aa. REGIST AR- 5i ature For State or ounty uSe only 45. DATE FILER (Month, Day, Year)
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<br />46
<br />49
<br />56
<br />MEDICAi. CERTIFICATION
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<br />46. PART I. Enter the diseases, injuries, or complications that caused the death. po not a ode of dying, such as cardiac or respiratory arrest, shock, or heap failure. UST ONLY ONE CAUSE
<br /> ON EACH LINE, APPROXIMATE INTERVAL BETWEEN ONSET
<br /> ANO DEATH
<br />IMMEpIATE CAUSE 1Final
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<br />DUETOIORASACONSEpUENCE 1:
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<br /> DUE T010R AS A CONSEDUENCE OF1:
<br />SrqueMiagy Gat conditions, if eny,leading to
<br />immedjatecause.EmerUNDERLYINGCAU5E c
<br />(Disease or injury that initiated events DUET0IDAASACONSEOUENCEOFI;
<br />resulting in deathllAST
<br />47. PART IL Other signiffeanl conditions contributing to death but not resulting in the underlying cause given in part I. 4B. WAS THERE A PREGNANCY IN LAST
<br /> 41 DAYSI ISpecity Yes, No, or Unk.1
<br />49.MANNER OFDEATH ISpecity-Accident, Homicide, Suicide, Undetermined Circumstances, Pending Investigation, Natural Causal 50. AUTOPSY 51. If yes, were findings considered in determiniraJ
<br /> cause of death)
<br /> 1Specrfy Yes or No) (Speedy Yes or Not
<br />52. HOW INJURY OCCURRED (Enter nature of injury in Item 46, Pgy1 ooltemd7,,Parl ll1 63, DATE OF INJURY IMonth, Dey, Year1 54. HOUR OF INJURY
<br />~" Y•ti 4,; . ,„ M.
<br />55. INJURY AT WORK 1SpecAy Yes or Not S6. PIAC ,
<br />Y~Specity at home, far , sfadon; oNice buiMing, etc.1 57. LOCATION OF INJURY (Street w R.F.D. Ne., City or Town, State)
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<br />This is a legal record and rliialst pe filed rvithi'n,five j5) d8ys^~fter:death. noPH•HS zine~. a r-sa
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<br />'This is a true axY"i~`exac~ copeof the:!record Bled with the Baldwin County Health
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<br />Signed: ~~ " ~ ~ Date: July 1, 2010
<br />Title: BAL IN COUNTY REGISTRAR
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