Mary Ann Kuhn3I
b0e'
A-
AL SOCIAL SECURITY NUMBER
ElL.48-i"jij, �'kS76.
I At— E.;
�411i�d)
TYE OR
"VIT,
11111"t bED"."
E
7�h$
Hours: Its
PRINT IN
6, DATE BIRTH.(Month, Pay, %ar)7.BlFtTHPLACE(CIyandStat..,IbbignCountry)
fl WAS DECEDENT EVER IN US
PERMAN
CE FI FZEATH�
Omaha, Nebraska
ARMED F•RCES? (*s >, Nol
8
I�FILE N& 'F LomiA 7"
0
1. PECEDENT*$ NAMEkFIS1, MIDDLE LAST' 2.,SEX
'a
J1
M
'MaryAnn;? 4ema1e',
ry
9e. COUNTY OF DEATH
7
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'3. DATE OF DEAJH(iMorth, D,% Yw)"
AL SOCIAL SECURITY NUMBER
ElL.48-i"jij, �'kS76.
UNDER I.. EAR_ 1 Sc. NDERtDay.
�411i�d)
�'571 �1�22, -,,9503
1, 1
{,ea sl ,70-\
7�h$
Hours: Its
EEE
6, DATE BIRTH.(Month, Pay, %ar)7.BlFtTHPLACE(CIyandStat..,IbbignCountry)
fl WAS DECEDENT EVER IN US
ebruary 23,1929
Omaha, Nebraska
ARMED F•RCES? (*s >, Nol
0
gai; PLACE OFOEATH (Ctwk only we: see instructions on other side)
HOSPITAL inpatient � ER/OulPat io i _r_ DOA OTHER:_ Nufling Home _XRorxit side—Other (Specify) :
9b. INSIDE PTY LIMITS? (%a or No)
No
NAME (11 not Inslito
9c. FACILITY(!on. Vine )I(met ..d -.be,) Sid. CITY. TOWN, OR LOCATION OF DEATH'
9e. COUNTY OF DEATH
7
'Hiclloi�YHcili'_
<9705 R8ad—#9 5
Joke
aN
WORK DONE
10.. DECEDENT'S USUAL OCCUPATION
10b. KIND OF BUSINESSANDUSTRY
11. MARITAL STATUS -Married.
Ne— Wxf—d.
12. SURVIVING SPOUSE (it wile, gins maiden name)
DVMNG MOST
0, WORKING
Married;
D—ed (Spoody)
LIFE',00 NOT
OwrHome
Widowed
UBE RETIRED:Homemaker
7777
I11_',RE1I1E"1E,—STATE
IN,. COUNTY
13c. CITY, TOWN, OR LOCATION
I3d.STREET ANq NUMBER
Florida
hake
Leesburg
9705 Hi6koty Hollow Rd. #95:
13e. INSIDE CITY
131. ZIP CODE
14,,"W A PIN,
I
ACE, ri�an Indian,
1�. DECEDENT'S EDUCATION
• LIMI
S=CEDENTOFHISPANiCORHAfT(ANO
No or Vits in.
11).s spao�Haitian, 'u"
• hhur.tan. P-1 No Y.
81 cklvn ii. etc
Sti-ity.,
SpiHity only highest guide too
4"Td'd "Y I
(.7
'No
Socitio- "I I .1 1 1
'White ,
17. FAJIER:S NAME (Forst, Akdorit. Law) 'I
MOTHER'S NAME (Feist Middle .MadonS.rmama)
Miller
Isab6l' Thomas —
l9a. INFORMANT'S NAME (Typtatinni)
19b MAILING ADDRESS ($treat and Numoar or Runiliti.f. Nurribe,, City or 7owit, Star., Zip Code)
Carol Sudduth
5972,County�Road:P. 25 Kennard, Nebraska 68034
20a. METHOD OF DISPOSITION
20b PLACE OF DISPOSITION (Name o4cametery, crematory, o1T
C
2 LOCATION -City City or Town, State
Elitist )L Cfemawn' Removal from Slat.
Phil
Mid Florida Crematory
Deland, Florida
the'(Spoc
21a. SIGN URE
IIFIE.Filllll���IALSlFilICErEEgn
2lb.,LICENSE NUMBE13
21C NAME AND ADDRESS OF FACILITY
AICT�
01 ACTI,
&[GAS
7
SteversoBuHamlin',&,Hilbish Funeral Home
J-7
226 E. Burleigh Bl� Vad l a � Tav res, Florida 327
T?, """Ini'�
22 1,�—ICcrqe, dea
dee at the time, date and piece and due to the
23a. on the ba unut.l.on a hi.. death �6dd
01 exam " ' I
is at. j
dsis
(helime. ateandpi.1c.l. duolithl.",
'12 -wit and Title)' 1,
(Signature and Title)
-22b. DATE SIGNED (A&. Day. OF DEATH
23b. DATE SIGNED (M Da y",
R OF DEATH
21, HOD
E0
M
EW
og August C)s ICICIC111
F"I 10:42 A m
13Z
SE 22d� NAME OF ATTEND PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
FXAMINER`SCASE0
9,23d.MEDI(�,Al
9- 9-. 0-`5_ 0 L: L. 10, 2
24. NAME AND ADDRESS OF CERTIFIER PHYSICIAN, MEDICAL EXAMINER) (Type arPfinf)
EIr.,"Susaqkendon,'M. D. 402j, East Dixi�,Avenue, Toesburg, Florida 34748
25.. SIJBREGISTFIAR —SIGNATURE AND DATE 211 L L REG\1STRAR — Sl TPRE C_ DATE REGISTERED
AM5?
l the mod.
Zb FAKI I. fa Idle.
the diseases. Injuries, Of complications that C. rl� _hs raNt'it, _m. . ueory attest. shock, or hoarl I
a. - lip" in",
alule.lLsionly one caussioneac line.
Onset and
Death Ij
Pan ll
IMMEDIATE CAUSE (Fir
di".. or -."'I
a Acute Coronary Insuffiency
DUE TO (Oft AS A CONSEQUENCE OF):
IfaIf an I.. y r1o, d%','� It rf. Di ,�paqp
"teri DUE TO (OR AS A CONSEQUENCE OF):
ca4s¢ (a, UNDERLYING
CAUSE "a' so emfu
At tritiated
Nils ., l' aalh) C
DUE TO (ORAS ACONSEQUENCE OF):
PART ILOthefaignil—Icond,tion cons .b.hng to death but not fesuliN 16 thd27b. WERE AUTOPSY FINDINGS
\1"27a, WAS AN AUTOPSY
USED TO TO MEDICAL
underlying cause g-ut Part I PERFqRMP.01COMPLETE
or mod OF DEATH? (Yes c
6hroni 6 'Alcoldism NO
-29, IF FEMALE. WAS THERE A -Aa. IF SURGERY IS MENTIONED IN PART,I or 11 ENTER CONDITION FOR WHICH IT WAS PERFORMED DATE OF SURGERY (Mo. Day, Wall
32! ME
� PR GN
qANCYI� THE PAST
3 HS? 'YES
NO
INJURY' 32b
R
32a DATE OF INJ TIME OF �2c K? 32d DESCRIBE HOW IN
31. PROBABLE MANI)EROF , J, "I "I
(iMom". Day.
INJURY
lluirt INJURY
DEATH INJURYAT WO
fSpoor (Yes or No)
stilcide,
I.Nithuld.
M
�211
Natural _320 PLACE OFIN "At home. farm,
321 LOCATION (Street and N. -b., or Rural Rout. Nuuribo,. City or Tovn. Stairal
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THIS IS A CERTIFIED TRUE AND CORRECT COPY OFJHE OFFICIAL RECORD ON FILE IN THIS OFFICE
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S`Wte f#eglstrar'
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24. NAME AND ADDRESS OF CERTIFIER PHYSICIAN, MEDICAL EXAMINER) (Type arPfinf)
EIr.,"Susaqkendon,'M. D. 402j, East Dixi�,Avenue, Toesburg, Florida 34748
25.. SIJBREGISTFIAR —SIGNATURE AND DATE 211 L L REG\1STRAR — Sl TPRE C_ DATE REGISTERED
AM5?
l the mod.
Zb FAKI I. fa Idle.
the diseases. Injuries, Of complications that C. rl� _hs raNt'it, _m. . ueory attest. shock, or hoarl I
a. - lip" in",
alule.lLsionly one caussioneac line.
Onset and
Death Ij
Pan ll
IMMEDIATE CAUSE (Fir
di".. or -."'I
a Acute Coronary Insuffiency
DUE TO (Oft AS A CONSEQUENCE OF):
IfaIf an I.. y r1o, d%','� It rf. Di ,�paqp
"teri DUE TO (OR AS A CONSEQUENCE OF):
ca4s¢ (a, UNDERLYING
CAUSE "a' so emfu
At tritiated
Nils ., l' aalh) C
DUE TO (ORAS ACONSEQUENCE OF):
PART ILOthefaignil—Icond,tion cons .b.hng to death but not fesuliN 16 thd27b. WERE AUTOPSY FINDINGS
\1"27a, WAS AN AUTOPSY
USED TO TO MEDICAL
underlying cause g-ut Part I PERFqRMP.01COMPLETE
or mod OF DEATH? (Yes c
6hroni 6 'Alcoldism NO
-29, IF FEMALE. WAS THERE A -Aa. IF SURGERY IS MENTIONED IN PART,I or 11 ENTER CONDITION FOR WHICH IT WAS PERFORMED DATE OF SURGERY (Mo. Day, Wall
32! ME
� PR GN
qANCYI� THE PAST
3 HS? 'YES
NO
INJURY' 32b
R
32a DATE OF INJ TIME OF �2c K? 32d DESCRIBE HOW IN
31. PROBABLE MANI)EROF , J, "I "I
(iMom". Day.
INJURY
lluirt INJURY
DEATH INJURYAT WO
fSpoor (Yes or No)
stilcide,
I.Nithuld.
M
�211
Natural _320 PLACE OFIN "At home. farm,
321 LOCATION (Street and N. -b., or Rural Rout. Nuuribo,. City or Tovn. Stairal
RY'_
ledOY J�c "piray),
e
D 5
THIS IS A CERTIFIED TRUE AND CORRECT COPY OFJHE OFFICIAL RECORD ON FILE IN THIS OFFICE
U
S`Wte f#eglstrar'
fAi 06EP-P4 SEC lTER HE k,
q�- 6 P 1C MARK OF tti�, T
THIS qgEf IJR1T)`, PAF`ERNV1jH,,A Wie
THLIPRESENCE OF THEMATE RK,
�1,15L �Tg,/W
,�,,LOt,,IHLb]AiEOFFJ-013[DA.�DO.NOTACCIEPTWITHOUT,VE - A1F*<JNG,
fAw R N, I N
'k v FLORIDA DEPAIRT
OF
Gq('R,.Ek4B0SSED'beA T
-6�tff jNS-kMIJLi.1-CCk04D EkktORCIW401 IAII� L. jH5!;,BAQ�
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INES WIT�i TEXT cs ]k HIER 0 M1 t
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