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HomeMy WebLinkAbout2650 ~i 234'~20 NAME: F~RST MIOOLH ~,AiT 2. i~i iA. Ow7C O~ O[wTM 3B. NOU11 V~Lt •~MAL< MOMTi1 DA11 •[AI~ ~ Tthel Virginia Purkey O e9 16 ~1970 3 s 15A~.. , 2 ~ ~ •~C~: l~I1N1~C. N[6A0. s. AG( If UNDE• 1 r~. ~r UNO(A ~ OA. oA. V[TE11wN O~ ~/.3. AAM(O ~OACCS~ 6B. YES- SnEt~ilt WAR~ OA i u.1[111C~N tND1U1, ETC,1 riONTH3' O~r3 MOVPS ,~+1N. i OATES Oi SE~YIC[ ~ ~ ~ , white ~ ?[S NO UY0.NOMfN o )n ~ 2fi ' ~ ~i ? ; WW 2 d . ~ A 7A. CO:7~li? /NV Sl 178. TOWN ~ 7C. C1)Y OA YILL~C( ~ 7O. ICNGTN O~ STAt IM ,7E. NOS?1TAl OA OTMEI~ IN57/TU~IOM t 1 ~ ~~OWA, CIT~ pl~ VIllA6C1 ~1~ NEITw[A. CIV( STAECT ~ NO.) ~ Oneida ; :Rome ; ' 28~5 USAF Hospital o Ye rs ~ e.3f~fC Or ~IATM OEC[OEkT SOAN IO. C1TIj[N O~ YfMA7 I1. MAAI~AL ST~TUS I2. SUNVIVIMi 5?OYSE I11 WIFC, M~ID[M NAMC.I (COUNTR~,IFMOTySA 40NTN DA~ •[~11 COUNTII~~ Kentuck 7; 20~192 USA married Gerald L Purkey 13A, ~SY~L OCCUPAT~OY ICYLN ~f pCT:D[DI ' I3B. IlINO O~ OUSINE55 OR INDYSTIIII '/3C. SOCIAL S[~UAITY MO. Housevife ~ ~ " nIa , ~ r ~ I~A. S~~~t ' 1{B. CO'.MT? t 1~C_ TOWM ~ IID. CIT~•0~1 vtllAGE 1~E. WITN~N TME 14F. 5T11[[7 ANG NUM![R ~ I I C011VONATE LIMITS! ~ C ~ ~ ` : ev York ; Oneida ~ ~tome i~ ~ i2623 Thor Avenue ~ r 1SA_ iATMEA~S M~uE: ISB. YOTNE~1'S wA1DEN HA~AE: ' ~ f~AST tyi00lE LAST i1p5T 1JIODLt LAlT t l ' ' 1 13ectel 16A. IMiORV.?hT'S AIUrE: '168. u~1~ING ADORE55: l1MClU0E 21v COOEI . Gerald Purkey ~ 2623 Thor Ave., Griffiss AFB, Rame, New York 13440 PART 1_ DEwiN WAS C~USED !Y EYtEw ONt,? ONE C~USE PEN LINE f011 IA1, (B~. /~NO (Ch AvPROi1WATE INT[11YAL ~ lETWEEN ONSET t O[ATN 17- ~MMEDIATE C~USE Cardiac failure 11 hours OU[ TO 011 AS A CONSEQUENCE O~ CON01T1pN5, IF ANr_ NNICM GAVE 1115E TO :MMED~ATE ~QI Possible ~rocardial infarction C~USE IA~ STAT~M6 TwE YNO(RLVING C~JSE lwST O~E TO OI~ AS A COASEOUENCE Os ,~,Arteriosclerotic heart disease PART 11_ OTr.EI~ SIGV1f1GANT CONDIT~ONS: COND+T~OMS COKTRIlU1+NG TO ISA. AUTOPS?~ IIeB, 1/I/ES.WENEi1MO1N65 CONSIDEREOIM G[ATr •JT MOT ~[~~TEO TO C~USE GIVEN ~N oART 1 IA/ •ES w0 ~ DETERM~NIXC THE CAUSE Oi O[ATMT Z ~ ~ 1 TES ~ NO ~ O ~ z f - - - ~ t 19A. ACUDEM7, MOYICIDE, ~198. MC4TN~On1~~EAR 19C reOUR 19D. NOw O~D ~NIYN~ OCCUM~ tENTEN NATURE OF INIYN~ES IN +17 1, 011 11.~ V SU1C1D[_ uYCETERUINED i . 1 4 . 1 1 ~ ~ ~ M. j ~ 19E. ~w~u~r •T WOPK? I 19F. o~wt[ os INJUN~'. NOME, 19G. LOCAT~ON (S7REET 6 NO.. CiTY OR vILLI~GE, TOMIN, COUNTr, STATE~ '2 tE5 NO I FACTORII, O~FICE 6lOG., ETt, 1 I u1 Q O 1 ~ i V E < TO BE COMPLETED BY TO BE COMPLETEO BY ! " 20. OART 1 CERTIFYING PHYSICIAN ONLI' ~R 20. PAHT 11 ~RONER OR MEDICAL EXAMINER ONI.Y € (0 A,TO TME •EST O~ MY ¦NOnOLE6GE, DEIITM OCCURRED •T ON Te~E OA5~5 OF EnAMINAT~ON AND/OR tNVESTIGATION, IN MT ~ W 7ME TIME, OATE AMG VC~CE ~ND OYE TQ TNE •wpNTN DA? •EAR ODINIOM ~E~TH OCCUpAEO AT TM£ TIME~ D~TE ANC PLA~E 41D ~ ~ C~USES 5• EO ~ ~ OUE TO TME CA:lSES ST~TEO. - Ir .yj/.~.Q . ( SIGNEO..... ..ta!~!n~~!!/V..[..ll. . ,TO SiGNED_......... ~ ~ TITIE......... ~ B. TNE PNISICIUT ATTENDED TN[ DECEASED C_ LAST SEEN AL1YE B. ORpMOUNCED DEAD C. MOUR D. DATE 51iN[O upNTN 011? EAII MONTM DAr rE/~R MONTN Dnr YEI~N MO*7M DAr rEAR MOMTM 0~11 YEAR , rROw: ~~~'~~~a~ ~ 1-j! ; `-~"V 'IS : ~ 7G oM ~ ~ ~r ea. ~ ~ Jj.l ~ D_ ATTE4DI;r~GN IAIi, 1~O~M n'1)1!1 t~ENtIf1~A~- E. COROMER'S OM?SIC~AM, Ii OTME11 TM~N CERTIFIER: 4 . ~'J 21_ NAMC 4Rpa~pAES10i CEAfIFICR 1?NYSIS~µ. ~OpONEA, MEOIC~L E~AMINEN, CORONEN'S PMYSICIAN~ MEOIC~L DIRECTORI: Kennet~'i ~t ~ x. 284 i Hosp. Griffiss AFB, NY 134~0 _ , - f 22A. lu11i~~ Cr(EwAT10~1~![N AL MONT~1 D~r ~7E11* 228. PLA[E Oi lURIAL, CREMATiON OR 11EMOVAL 22C. LOCATION ICIT? OR TOwM, STATE~ ~ f~ • j •.-Q-;~'.~'~.~ ]97 Arlinoton ::ational Cer.~et ry Arlington, Vir~inia ~ 23A. NAML~AMD~~ DD~~SS OF IYNEwAC N~M ~ ' 238. 11EGISTI~ATION MO. 4 :Iartin~-,J.~' utin••Fan~ ~ ' ~&f~ Nome, Inc. , ~ Q 21A. N~n.~E Oi FUMER~L 0111€f O.•,,`~•~ 2AB GNAT~E O~ fuNERAI OIRECTOR '24C_ IIEGISTI~ATIpN NO. ~ artin J. :dunn ~ ~ ' ~ ~ ~ 002959 . ~ ~ - ~ - :s s. ~ i 2SA SIGNATURE OF 11EGISj/MR MOMTN DAT •CA11 26A. OU AL OR PEM0~41 PE~ ISSUEO 268. MOMTM OAT •EA11 ° OAT[ ~ . ~ . - ..............•ll..................... siLED ~ ~ Sr:.... 1 / ~~s ~7 ~ . 3 /8~ 7d ~ ~ 234'720 fILEO AMD RECORDEQ ~ =T. lUC1E COUNTr FLA. ROCEn FO~jRAS CLERK CiRCU17 COURf RFCOFJ VEpiPIEO.r.~.~~ At~ ~I 2 0~ PN'7Z ~oac204 r~c`1~4~ --sC'~Lt~G~ ~ ~ : _ - - E ~ ~e.. ~ _ . - - _ ~ _ ~ ~ ~