HomeMy WebLinkAbout062451629~~
^ =Ci:l': ~C
: c CDRDJ $fC11~1 11 •• ~~'i ~ ~r C
~E(I ~; ~ L`u'.`~ ~:: ~.
a~c Kead
~rc~f-~lte
': r~~fully
it~ m of in-
::on should be
:ly' supplied.
~s ~houid .be
e w r i t te ~
~inted in pep
nt t~ pc blacl~
certificate be-
s a permatletlt
reccrd vehen
~rl}~ cxecuted.
rr tu submit a
ficate of Dealh
i:~ Depariment
Human Rr
es K•ithin 48
. aCtcr death
~
' < <iolation o[
a:~s of the Dis-
nf Columbia.
:TIE'IE:R
i~s OUT---
OR "THIS
~I HOSPITAL".
Ili
;i .tion of these
i is punishable
:~c ur imprison-
C : ~~r both.
;9
~ _
~ - --
~ ~-uasT 28. ~98p --
(Dsted Iaaued)
r.o..~~~~ ;:: ~~~.~ :
VITlt;. ~ EC~ ;i,~ ~~~TiJ~~
DISTRICP OF COLUMBIA
DEPARTMENT OF HUMAN RESOURCES
CERTIFICATE OF DEATH
80-00558T
~'
FILB DATR Fil~ No.
1. NAai6 OF DECEASED Fi.if AlldJle La~f 2a. DATB Vonlh UoY Yeor ~ Zb. Hout ot DeaW
t~~ ~~~~ v,ARGOT LOUISS DE;~IOREST uewTH AUGUST 24 1980 ! 10: 0~ AM
3. SEX 4. COI.OR OR RAC~ S. Nevec Dtacried. 111uried. 6. DAT6 OF BIRTH - 7. AGE (In ycon 11 Vn 1~ Under 2~ Hjj
Widor-ed. Ui~oreed: Speeitr ~Y?-1~~ foft_birthdcyl ~lonfAa Uoys Hours ~ Nin.
F1~3dAT.k' ~jj~$j~ ARRT .D ~{~
8. PLACE OF DEATfi IN \~'gShingtoD, D.C. 9. USUAI. RESIUENCF fN'herc deceased Ilved. 1/ frutt(utlon, nsldencs
\AI~fE OF lIOSPITAL. I~VRSI~G !t():11F Olt UTHt.It IrSTITtiT!(1\ ~, STATF. ~ b.CAUNTY , 6~lorr odmisalunl
(// nof (n insfifut(on, ~~i~e strcet adJieu) ~~Ba~~ ~ rl~1.S0a`~
INSIDS CITY LlblITS
e. CITY e. (SPECIFY.Y6S OR NO)
WALTER REr D ARMY 2~~:DICAL C~iTER :iUNTSVILLE (~580~ ) YES
d. STREET ADDRESS 1!/ w~ul. Live lotatton)
555 F~tF:Ct~IVE DRIVE APT/63
lOa. USUAL OCCUPAT/ON (Gi~r kind o/ wo~k lOb. KIMD OP BUStI~ESS OR 11. BIRTHPLAC6 12. CITIZENOF WHAT COUNTRYt
done du-in mo:f o/ +uorkint -i(e, et~en i( nfired) USTRY ISfafe or jonlpn eountry)
HOUSE'~I~II~'E 1~~~ ILLINOIS USA
13a. FATHER'S NAMB 13D. NOTHER'S AlAIDEN NAlUE U. NAAtE OF SURVtVlNG SPOUSB
THEODORE LARSON tdARGA.RET BOw'GREN EDWARD H. D~fiiOREST
1S. E~•ecinU.S. 16.SOCIALSECVKITYI~O. 17a. 1:\FOR\fANTRELAT/01~St/fPTOUECtASL~'D17b. ADDRESS Street City State
Armed Forees?
HO 343-30-1073 ED~~ARD H. DFMOREST/HUSBAND/SEE ITF~I IY9
ls. CAUSE OF DEATH: IEnter only one eause per fine /or (o/, (b), and (c). J ~ Inle~vd Betwetn
PART 1. DEATN WAS CAIISFD BY: I Onset wd DeatL:
Il-1AfEDIATE CAUSE (a) CARDIAC ARR~.JT ~
Conditionr, i/uny, ' ~
~ u~;~s ee~r •~~ r~ DU6 TO (b) RENAL : FAILURE ' ~ ~
ubort c'our~ [c/. sfaF ~,
0 fn~ the w~derlyins taust ' . I
E 1at. .
E uus 1'0 (c) COROMARY ARTERY DISEAS~3 ~
V iART 11. OTH6R SIG!CIFICANT COI~DITlONS: tont~ibutin~ to death but oot 19a. AUTOPSY? 19b_itYes,Were FlndiajsConsidered
~ related to the termina! disease eondition ~iven in part 1(a) YES OR NO ia Determinin~ We Guse o! Deat6T
a!F OP£RATiON WAS PERFOR111ED 20a. DATE OF OPERATION 20b. CO\1DITtOf1 FOR WNC N OPERATION
~ COlfP1.ETE 17'E-IS 20a and 20b \YAS PERFOR~IED
'~ Z1a.Speeitr it aceldent,sufeide.homl- 21p. NOUR AND DA?E OF lNJURY: Monlh,Day,Year 21e. DESCRIBE HOW INJl1RY OCCURRED
V eide. or manaer undetermincd _ (t'nfer naturc o/ /njurY in Porf I or Pbrt !1)
~ K
Q 21d. IN~URY AT NORK: 21e. PLACE OF INJIJRY: (,It Home, Furm, 21t. LOCATION CIl'Y COUNTY STATB
~"~ 1Speei/y Yts or 1~0) Factory,Sfnet or U//tce Buildin~, t f~_) •
~ '
22.1 certity that (Xj (lbis hospit ) attendcd the deeeaxd t om _Z _~~G~ST ~.., ~ gHQ_~ ~ 2~F A~iUS7' ~ lg~~~ ~~~t `t) (we) 4st
sa~r the deceased alive on .~~..gUGjj$Z__.,,.. 19 ~_..and that death oceuaed trom Ihe eauses aad oa the date and hour staled abore.
22a. SIGNATU . ~Z2b. DATE~IGN6D
`~// /~~• !~~! •1• PHYSNDIN~ D RECi'ORO HYSF g! 24 AUGUST 1980
22e. lNYSICIAN'S ~ 22d. ADDRESS .
AIA\tE (Trpe) r,~pRg A. GREE2~B~RG A~, CPT, tdC ~ ~25 16ST NW WASH, D.C. 20012
23a. Ei7R1AL p~ Z3b. DATE 23e.\A~fEOFCEAfETERYORCRE1~fi-TOR1f~23d. LOCATiON (Gtifr. tou~n, oreounty) (Stats)
CRE~tATtON [~ +
REAfOVAL ~_ 8/27/80 Ar~lin~ ton Cemeter , i Arlington,Va.
2~. FUNERAL HOaiFH~KY,~'S-R~I AT,D-I _~' Ul`r.tWli~i ~..y ~. KER• IGNATURE 25b. 1TNDERTA~CER•S /1~ r~
ADDRESS 21800 NEW HAA'SPSHIRE AVE, SIL .°~~ HU~1SERA?ION ~Q h
~~ ~
REatARKS: ~ !!•,- ~ at
Authority is granted for cremation by . ~~, } ~; ~
b:, . ' ` ~S% '~
cammer or x taure *,~
• . .% . _ . ~s~. Date:
u
I CER'I'IFY that the above is a true and
certificate filed in order xith the Yi
Columbia Department of Public Health.
~<<i ~ .- „ ~ ~
~y_ : s ~.~`-
!-~ ~N1
n of the original
, Distric o
ohn H. Cran l, Chief
• Vita1 Records Division
NOT VALID IiITHOUT RAIS~ SEAL ,.
.~ 16~~c~
198i F~~' -9 ~~~~ ~f- 24
F~tc~ c~.< <:~.~:~:~.:~
51. LL'f.lt C;•U~ + Y. f!:..
ac!GFR ~Oi ; Rr.S
CIEF.K Cif~J'? Cf~ //
- . •~.,~... f
g~348 Pd~E 624
f~
:~
~
~ _ _ -- - a~:
= ~. ~~w~~~_:~ __. . _, __ . _ .._.