Susan PertersonN
CITY OF DALLAS, TEXAS
2. DATE OF DEATH - ACTUALORPHESULAED
VITAL CS DIVISION
z
4 . i -i- A U A- -i: 11R
�i� X. KI so=
Female 01-18-1953 (Yeats) 54 - A - Mayesville, Missouri
a
41
STAT OF T Ab %On I Ivi- - -1
1. LEGAL NAME OF DECEASED (Include AKAJS dany)(First, Middle, Last) (Maiden)
2. DATE OF DEATH - ACTUALORPHESULAED
Susan Petdrsorv. Osborne
z
4l DATE OF BIRTH. WAGE-LastBirthdayIF UNDE IF UNDER I DAY 6. BIRTHPLACE (City & State or Foreign Country)
Female 01-18-1953 (Yeats) 54 - A - Mayesville, Missouri
7. SOCIAL SECURITY NUMBER 8. MARITAL STATUS AT TIME OF DEATH XMarrled 9. SURVIVING SPOUSE (it wife, give name prior to first marriage)
11 Widow ad 1) rvorced
507-74-045,8 D �,D i4y., Mwded: El 64111,0 Ric Pdterson:::.:
:100. RESIDENCE STREETAODREPS 10b: APT loc. CITYOR TOWN
FFF
10d. GO �TA IGLZIPCOQE 109, INSIDE CITY Y. LIMITS?,
QNTY XY.s FJ No
=1.
S 7.5236
Dallas XAS
ii. FATHER'S NAME
12. MOTHER'S NAME PRIOA TO FIRST MARRIAGE
Delbert Osborne
Delores Follef
ONE) ... ... ..... .... .. 13. PLACE OF DEATH [CH ECK ONLY Q
IF DEATH OCCURRED IN'A HOSPITAL:
.
�jRo D�SOMEWHER�E(OTHERliiANA'kOSPffAL�
Other IS -11y)
Q)
❑ Ho I. Facility Nursing Home D D6.edent's Home P
dp
W
Dallas 7523T, Methodist Charlton -Medical Center
Dallas,..
17; INFORMANT'S NAME& RELATIONSHIP TODECEASED ::IA.MA�ILING;ADDRESS�PFINFORMANT (stieetand Number, C!�y,s te, Zip Code)
Rick Peterson Husband ' -�Qnq Mtirgawood X 75236
L5
0 Burial 9 Cremation 11 Donation ACTING' SUCH Section
D Entombment, 11 Removal From State X Block
[I Other (specify) Dennis W Jeter, #6067 Loi
22. PLACE OF DISPOSITION (Name of cemetery, Crematory, otherplace) ".. LOCATION (Clyfrown, and State)
"pace
Jeter & Son Cremation Center Da a Texas
LL
24L:NAMEOFFUNERALFACILITY
Illinois Ave.Dallas TX: 75211
J ete Son Funeral. Hmldrepatqr�i 4830:.W- I1
_.
C26.�C E IER (Check only one):
edifying hysiclan -To the best of my knowledge, death occurred due tothecause(s) and manner stated.
dy., P
11 Medical aminer patice of 4 examination, andor fnvespgallon, In my oplqton, dealh=..uffed at the time, date, and place, and due to the cause(s) and manner stated.
r
27. SIG UR 122V -'C PTIFIED.(
A : 36��,. P
7
31. PRI NAME, ADDRESS OF CERTIFIER (sTreet and Number, City, State, zip Code) 32. TITLE OF CERTIFIER
Au Stine Attiah 2707 Bolton Boone #100 DeSoto TX 75115 M.D.
*
33. PART t . ENTER THE E CHAIN QE VE -oisEAtES,lt4jUl5jES,bo.POMPLICAf!PNS-THArDiI iEcTL.,CAUBEDTHE0EATH.Do ENTER Appitudmatil,Interval:
r, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE onset to death,
TERMINAL EVENTS SUCH AS CARDIAC MMU.
r - DO NOT ASOREVIATL,,IENTER ONLY ONE CAUSE ON EACH LINE.
=TIOL00Y 61 224
E CAUSE (Final
IMMEDIATE
x CLL
Sequ..fisilly We to (qr as a Consequence 01):
R aq;,leading to the mum
2
U
listed on line a. Enter the
at
w
U NDERLYINQCAUSE Due to Lor as a consequence of):
(disease or Injury that
U
the events resulting
U
O
Initiated
In death) LAST. d.
LOT
PART 2. ENTER OTHER CONTftISUTJNG TO DEATH BUT I, RESULT!NG IN THE UNDERLYING
PERF
34. Wlk$.,AN AUTOPSY PER qRMED7
CAUSE GIVEN IN PART I.
Yes LI -M
35. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE:THE CAUSE OF DEATH? 11 Yes
36. I*NNER OF.. DEATH
D TOBACCO C.ONTRIBUTE�: 38.)P,�ISMALE: 39.IFTRANSPORTATION INJURY,:.
37. DI I - "
SPECIFYt.
[tN.tuial
TO DEATH? past
Silhot pregnant with(h pas EI Driver/Operator
z
0 Pregnant at time of death
D Passenger
11 Suicide
D No 11 Not pregnant, but pregnant within 42 days of death
Q Pedestrian
D Homicide
D Probably,. L pregnant, 0 pregnant b, days to I year, befcfq death
0 Other lly)
11 Pending Investigation
Unknown If a ::: . .1
Q Unknown turtwit,hinthi past at
pl�gl Y,
11 Could not be determi had
40a. DATE OF INJURY (MwDayN,)
restaurant, wooded was)
TIME OF INJURY 40c. INJURY AT WORK? 40d PLACE F INJURY (e.g., Decedent's home; Construction site, res
140b.
D yes D No
LOCATION (Street (Street and Number, City, State, Zip Code)
40f. COUNTY OF INJURY
41. DESCRIBE HOW INJURYOCCURRED
Z.,
REGISTRAR FILE NO
"
RECEIVED BY PAR
.. ST
42o REGISTRAR
-
02-00721
142b,pATI:
I
FEB 08,2007
bar�s
a
41
STAT OF T Ab %On I Ivi- - -1
1. LEGAL NAME OF DECEASED (Include AKAJS dany)(First, Middle, Last) (Maiden)
2. DATE OF DEATH - ACTUALORPHESULAED
Susan Petdrsorv. Osborne
january 31$..,20 7
4l DATE OF BIRTH. WAGE-LastBirthdayIF UNDE IF UNDER I DAY 6. BIRTHPLACE (City & State or Foreign Country)
Female 01-18-1953 (Yeats) 54 - A - Mayesville, Missouri
7. SOCIAL SECURITY NUMBER 8. MARITAL STATUS AT TIME OF DEATH XMarrled 9. SURVIVING SPOUSE (it wife, give name prior to first marriage)
11 Widow ad 1) rvorced
507-74-045,8 D �,D i4y., Mwded: El 64111,0 Ric Pdterson:::.:
:100. RESIDENCE STREETAODREPS 10b: APT loc. CITYOR TOWN
5909 Margewood Dr Dallas
10d. GO �TA IGLZIPCOQE 109, INSIDE CITY Y. LIMITS?,
QNTY XY.s FJ No
=1.
S 7.5236
Dallas XAS
ii. FATHER'S NAME
12. MOTHER'S NAME PRIOA TO FIRST MARRIAGE
Delbert Osborne
Delores Follef
ONE) ... ... ..... .... .. 13. PLACE OF DEATH [CH ECK ONLY Q
IF DEATH OCCURRED IN'A HOSPITAL:
.
�jRo D�SOMEWHER�E(OTHERliiANA'kOSPffAL�
Other IS -11y)
[Xlnpati _:: 0 �i VOutpatlent: 0 DOA:::
bid
❑ Ho I. Facility Nursing Home D D6.edent's Home P
dp
14, COUNTY OF DEATH. )TOWN, ZIP (if outside CRY limits, gave Precinct no) 16. FACILITY NAME (if not Institution, give street address)
Dallas 7523T, Methodist Charlton -Medical Center
Dallas,..
17; INFORMANT'S NAME& RELATIONSHIP TODECEASED ::IA.MA�ILING;ADDRESS�PFINFORMANT (stieetand Number, C!�y,s te, Zip Code)
Rick Peterson Husband ' -�Qnq Mtirgawood X 75236
19. METHOD OF DISPOSITION 20. SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON 21. R; Unknown
0 Burial 9 Cremation 11 Donation ACTING' SUCH Section
D Entombment, 11 Removal From State X Block
[I Other (specify) Dennis W Jeter, #6067 Loi
22. PLACE OF DISPOSITION (Name of cemetery, Crematory, otherplace) ".. LOCATION (Clyfrown, and State)
"pace
Jeter & Son Cremation Center Da a Texas
, .
3S OF FUNERAL (Street and Number city, State, Zip Code
2fi. COMPLETEADD tf In
24L:NAMEOFFUNERALFACILITY
Illinois Ave.Dallas TX: 75211
J ete Son Funeral. Hmldrepatqr�i 4830:.W- I1
_.
C26.�C E IER (Check only one):
edifying hysiclan -To the best of my knowledge, death occurred due tothecause(s) and manner stated.
dy., P
11 Medical aminer patice of 4 examination, andor fnvespgallon, In my oplqton, dealh=..uffed at the time, date, and place, and due to the cause(s) and manner stated.
S 30. ili�i OF pre
aylytj* a NUMBER
27. SIG UR 122V -'C PTIFIED.(
A : 36��,. P
7
31. PRI NAME, ADDRESS OF CERTIFIER (sTreet and Number, City, State, zip Code) 32. TITLE OF CERTIFIER
Au Stine Attiah 2707 Bolton Boone #100 DeSoto TX 75115 M.D.
*
33. PART t . ENTER THE E CHAIN QE VE -oisEAtES,lt4jUl5jES,bo.POMPLICAf!PNS-THArDiI iEcTL.,CAUBEDTHE0EATH.Do ENTER Appitudmatil,Interval:
r, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE onset to death,
TERMINAL EVENTS SUCH AS CARDIAC MMU.
r - DO NOT ASOREVIATL,,IENTER ONLY ONE CAUSE ON EACH LINE.
=TIOL00Y 61 224
E CAUSE (Final
IMMEDIATE
a.
pesultingindeath) :. , . ... .. me
list catfilk
Sequ..fisilly We to (qr as a Consequence 01):
R aq;,leading to the mum
ui
0
listed on line a. Enter the
at
w
U NDERLYINQCAUSE Due to Lor as a consequence of):
(disease or Injury that
the events resulting
O
Initiated
In death) LAST. d.
LOT
PART 2. ENTER OTHER CONTftISUTJNG TO DEATH BUT I, RESULT!NG IN THE UNDERLYING
PERF
34. Wlk$.,AN AUTOPSY PER qRMED7
CAUSE GIVEN IN PART I.
Yes LI -M
35. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE:THE CAUSE OF DEATH? 11 Yes
36. I*NNER OF.. DEATH
D TOBACCO C.ONTRIBUTE�: 38.)P,�ISMALE: 39.IFTRANSPORTATION INJURY,:.
37. DI I - "
SPECIFYt.
[tN.tuial
TO DEATH? past
Silhot pregnant with(h pas EI Driver/Operator
0 Accident
0 Pregnant at time of death
D Passenger
11 Suicide
D No 11 Not pregnant, but pregnant within 42 days of death
Q Pedestrian
D Homicide
D Probably,. L pregnant, 0 pregnant b, days to I year, befcfq death
0 Other lly)
11 Pending Investigation
Unknown If a ::: . .1
Q Unknown turtwit,hinthi past at
pl�gl Y,
11 Could not be determi had
40a. DATE OF INJURY (MwDayN,)
restaurant, wooded was)
TIME OF INJURY 40c. INJURY AT WORK? 40d PLACE F INJURY (e.g., Decedent's home; Construction site, res
140b.
D yes D No
LOCATION (Street (Street and Number, City, State, Zip Code)
40f. COUNTY OF INJURY
41. DESCRIBE HOW INJURYOCCURRED
Z.,
REGISTRAR FILE NO
"
RECEIVED BY PAR
.. ST
42o REGISTRAR
-
02-00721
142b,pATI:
I
FEB 08,2007
bar�s