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RACE OF
DEATH.
8.
DATE OF
BIRTH
MONTH DAY YEAR
MAY 14,
II
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WA :IIpECEDENT O II ISPANIC ORIGIN:
(SP -CIFY YES OR'I4 O
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IF UNDER 1 DAY
HRS. MIN.
B. COUNTY.
Fik'IrfZt F HA P'" IFtk
Cir
USA
IY MATORY N'AME)LOCATION
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39. vt! 14 T MOWN. N S Rosenian
DATE R AEG. FILENO.
m', r E 43 1461
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IF YES, INDICATE. MEXICAN, SPANISH,'
CUBAN, ETC.
C.HOSPITAL OR
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MARRIED, NEVER MARRIED,
WIDOWED, (MO IFY)
9.
,(tF FjE
III illl STREET ADDRESS),'
D. ZIP CODE
US LmriCU'"f ION "e
done most of working y life, 'even If retired)
1 .0OFTWARE ENGINEER
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49.
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M DICAL EXAMINE
OA`rS
JOHN
C. LAST
RACE (e.g., white, Welt, Amerman Indian, [specify tribe) etc.)
SPECIFY:. WHITE
INSIDE CITY LIMITS?
raffle IFVsYes
15F:
C. TOWN OR CITY
SADDI.EBROOKE
ON RESERVATION
(SPECIFY Yes or No)
,I FIRST
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?RELATIONSHIP TO
'DECEASED,
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PREVIOUS STATE
C4E RE$I F
INJURY AT WORK?
(Specify Yes or No)
STATE OF AR'IZO
COUNTY-OF PIM
This is a true and exact
on file in the VITAL RE
PHOENIX, ARIZONA. I
This copy not valid un:tes
ATE OF ARIZONA
SERVICES OFFICE OF VITAL RECORDS I EE 7. H NO
IRICATE OF DEATH U 1 02-
ADDRESS
95.
WHERE LOCATED
DESCRIBE HOW II
CERTIFIED COPY OF VITAL RECORDS
March 1, 2000
DATE ISSUED
roductioni.ot the document officially registered and to be placed
RDSSE'CTION, DEPARTMENT OF HEALTH SERVICES,
(ed under the authority of A.R.S. 36 -341, and by direction p
/A EC NO
URY DG CUFRED
WA
(SP
AST 8. MIDDLE
4S
17.
ELEMENTARY SECONDARY
10.12)
ExNNIS W,:DOUG�
IIIIII�iO
III, i{0ouhty Registr �l l'.
PII'O O?unty Health 0409Mment Ill;
1 !11 III''
engraved border displaying county seal in color and imprWssed hvttpt rai);Bd 1. of iSSUing.8 cncy.
DAY YEAR
1%,
DECEASED MA IN U.S. ARMED FQRcES?
I plFY YES 0E500 'IIIIYII;
I ra
030A
�iiOP EMER l iiii
1ID.IN PATIENT
¶FE;, I r IVE MAIDEN NAME) pull I
¢H T I "'pl!Iluu
IN i∎ •I BU R RY I'' II�iIbV
EDUCATION
HIGHEST GRADE COMPLETED
COLLEGE
(1-4 or 5
8. S'}
C. LAST
KATCHANKANN
CITY AND STATE ZIP CODE
T)ON ANI�r "1 ESTIGATION INlld dip 1 N'OEATHO "RE
D'P CE DUE TO THE CAUSE(S) AND MANNER STATED.
ip 6 I, id l it 11111 ,,11,1j1.11
HOU 'D' D 11 AT
PRONOUNCED DE IP (Hour) il
38 I' T
k'I'El tlj EC'D. IN ST TE OFFICE
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WAS CASE REFERRED TO MEDICAL EXAMINER
(Speciy,Yes or No) Y�r..Mt
R NOTE O01101A"'` °4 ANY ALTERATION OR E
OILS THIS CERTIFICATE
APPROXI-
MATE
INTERVAL
BETWEEN
ONSET
AND
DEATH