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TE OF TEXAS CERTIFICATE OF DEATH STALE FILE NO
V 1 ti/E OF i JaJfrst (D, M,cFJIe------ }cJl asl----~-'- ? $T If t OA1~ r)F UfAL• .
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~ [Tyl»alx~+u _ _ Samstone _ _ _Hol_mes __Male 2-_19-80 _ _
F t RAGE `ra WAS THE D[GE UENT Ui t IF YES.SPE GtfY MirILAN G UAIE OF 6tRIN I AGE(tn yeas: IF UhUER t .(AN 1 tr •.;)LR ?t t
Q p~ SPANt H ORIGINS t,UF1AN. PUERTi) {ALAN, list b ,tAday} r ,
II(Illte 1_ - I~0 - E1C- 5-5-11 68 - M •ntns Jf~•. / •n
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J Ya PLACE OF DEMH - CUl)NTV ~ MO C11Y OR IUY+N (11 oulswk ul r !~•r•IS. y,v! 8c NAME QF (fl nat :n h>sp,tat. q•+^ ttr=•=•' a~drec5} ~.I rN ~f?' C
~ prM.,rrc!-wJ IrOSPITALOR Lltrti~.•
Dallas_ Dallas iNSTI,UTrON Presbyterian Hospital Yes
LL 4 MARRIED NEVER MARRIE O. 10 &RThPI ACE (Staled tt CITIIENGi YJHAT 1? WAS DECEDENT EVER ,3 SURVIVING SPOUSE p+ Mde, ma.dC• nana;
O WifXtWEQ D!vORCED (SOec,tyl r0"''9^ cn.=^tryJ COUNTRY'• IN U 5 ARMED FORGFS°
~ Married _Louisiana_ __USA Yes _ Jeanne Hendrix
W to SOf.!AL SECURITY NO. ISa USUALOCCUPAiION jG,A!kmdof wWk=Atrretlunng t$y NINU OF 9USINE`:S (T+1 INOUSIRY
mOSi al w•>rY r•p hle, tren d relwed(
~ 438-56-8681 Dentist _ __Dentist _
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m tEa RESIDENCE -STATE 16D fOUNTY ibr CITY (+R IOtNN pt outsrd! uty Irmris, r1Fx1 STREET ADDRESS r~•.rt
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t Florida Martin Jensen Beach Rt. 2, Nettles Isl_an_d_M96__6 2 Yep
~ t7 FAT RE WS NAME IB MOTHER'S MAIDEN NAME T9 SIGNATURE F INF OHM T
= Rev. N. Mi. Holmes _ _ Ma Stone Jeant(e H. Holmes_ ~
O ?C IMMEDIAtE CAUSE (Enter Onfy one cause per hne tw ta), lDl~!c)1 ~ In!MVat t+!Ir=-~
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F C PART OTHER S:GNif (CANT CUNUITIONS - L(NIUt1tONS CONi HI[+UTING TO (K AEN I:UT NOt RI L AII.U 10 r:A1C:F GIV(N IN t'Atr/ I Ar)'OPSY~ - -
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! OR PENDING INVEST lSpecifyJ (Mo. Oay Yr J INJURY
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o_ o ?3D DATE StGNEDjM, Da YrJ 7 - HCUHrJr (;EATr. c ;y) ~u, DATE Sr(,••F:'(M•, i,a: ~ I ~a'
W u- 4.00 P• t
W ?3d NAME OF ATTf ND,NT: VF1YStClAN It~pq Or pr.nll ~"W ?LJ i/tDNOJlIr-c i; j
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_ CRT yATiON REMOVAL (ST,ecdy; J`~L !!~F--~~_.L -?S. NAME 0= C[M1 lFRV fiR f,PEIAAT jt'V ~ ~ - - - --i--
O :Sa BU'~AI
°O Removal 2-20-80 Port Hudson Na onal CemeAter ~
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Port Hudson Louisiana Sparkman/Hi11c s .,_!Nd~"fhwes Hwy
:Ta I+E Gt',THFI, ~r=•• Nh (,p" r• DHY LO=-.n{ t=f isSiRAH Trs; SrGfJ [IIH4'r)f t"{.;.1 REGIS!? • •
1~:~6 MAR 4- 1980 ~ -
'4911
1980 Q?~Y 29 ~iPl 9 53 •
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ii ~.ur cov~TY FAA. WHEN IMPRESSED WITH THE SEAL OFT j` ~ r ~ tI
j~pG~P01TM5
t~~RKCI?NdIT CtuP,r THIS IS CERTiFIEO ' ~ F~ELAS.
_ TO 8E A TRUE COPX,~~~,~~},~ ~ ,
REfirRyYlR(h~ RECORD A~~~EQ ~ g EA . ,
A '~jj
ISSUED. ~ -
' OCAL REGIST ~ ,~;.'_;z~,t-.'• '
t DALLAS HEAL ~
~,,QE~'I~RTIVIENT
- arox~2 POLE JlJ1
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