Oscar Grimm PetersonTYPE OR
PRINT IN -� OREGON DEPARTMENT OF HUMAN SERVICES
B ACK INKNT 403293 HEALTH DIVISION
I.D. TAG NO.CENTER FOR HEALTH STATISTICS
CERTIFICATE OF DEATH �i3s
Local File Number
DECEDENT'S First
NAME
4. SOCIAL SECURITY NUMBER 5a. AGE -Last Birthday 5b. Under 1 Year
383-03-6487 (Years) 92 Mos. Days
8. WAS DECEDENT EVER IN
U.S. ARMED FORCES? HOSPITAL
❑ Inpatient ❑ ER Outpatient
X1 Yes ❑ No
9b. FACILITY NAME (if not institution, give street and number)
Hopewell House
State File Number
2. SEX 3. UA I t Ut- UCA I rl may, �ar
M October 15, 2003
5c.=Mins.
HPLACE (City and State or Foreign 7. DATE OF BIH I H (monrn, Lay, reap
Hours
ntry)Blair Nebraska September 21, 1911
9a. PLACE OF DEATH (Check onlyone)
❑ DOA OTHER Foster Care
O Nursing Home ❑Decedent's Home )VOther (Specify)
9c. CITY, TOWN, OR LOCATION OF DEATH 9d. COUNTY OF DEATH
t0a. DECEDENT'S USUAL OCCUPATION 10b. KIND OF BUSINESS/INDUSTRY
2 (Give kind of work done during most of working life.
Do not use retired.)
3
13a. RESIDENCE -STATE 1 13b. COUNTY
4
5 I 13e. INSIDE CITY 113f. ZIP CODE
LIMITS?
12
13
14
13c. CITY, TOWN OR LOCATION
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Specify No or Yes - If yes, specify Cuban,
Mexican, Puerto Rican, etc.) X1 No ❑ Yes
Specify:
11. MARITAL STATUS -Married, 12. SPOUSE (if Married, Widowed)
Never Married, Widowed,
Divorced (Specify)
Widowed Mary
13d. STREET AND NUMBER
108,9 1; VV Davjes Road
15. RACE American Indian, 16. DECEDENT'S EDUCATION
Black, White, etc. (Specify) (Specify only highest grade completed)
Elementary/Secondary (0-12) College (1-4 or 5 +)
JV Yes ❑ No 97008
17. FATHER - NAME first middle last 18. MOTHER - NAME first middle maiden 19. INFORMANT -NAME and relationship to deceased
Karl - Peterson Anna - Grimm Joann Miles Ste -Dau hter
20a. METHOD OF DISPOSITION ❑ Mausoleum 20b. otherCEEIOFeDISPOSITION (Name of cemetery, crematory, or 20c. LOCATION - City or Town, State
X] Burial ❑ Cremation ❑ Removal from State
❑ Donation ❑ Other (Specify) Blair Cemete
21 a. SIGNATURE OF OREGON FUNERAL SERVICE LICENSEE OR 21b. OREGONLicenLICENSE NO.
PERSON ACTING AS SUCH
CO -3139
23. DATE FILED (Month, Day, Year)
RESERVED FOR REGISTRAR'S USE
TO BE COMPLETED BY CERTIFYING PHYSICIAN
27. TIME OF DEATH 28. WAS MEDICAL EXAMINER NOTIFIED?
0630 M ❑ Yes ]V No
29. To the best of my knowledge, death occurred at the time, date, place and
due to the cause(s) and manner stated.
(Signature)
30. DATE SIGNED (Month, Day, Year)
22. NAME, ADDRESS AND ZIP OF FACILITY.
Gresham Funeral Chapel
257 SE Roberts Gresham, OR 97080
24. REGISTRAR'S SIGNATURE
TO BE COMPLETED ONLY BY MEDICAL EXAMINFH
31 a. TIME OF DEATH 31b. DATE PRONOUNCED DEAD (Month, Day, Year, Hour)
M M
32. On the basis of examination and/or investigation, in my opinion death occurred
at the time, date, place and due to the cause(s) and manner slated.
(Signature)
PP
33. DATE SIGNED (Month, Day, Year) COUNTY
34. NAME, TITLE, ADDRESS AND ZIP OF CERTIFIER/MEDICAL EXAMINER (Type or Print)
fil7i .. e Portland, UR 97236
35. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
CHECK APPROPRIATE BOX BELOW ... COMPLETE BOTH YELLOW AND GREEN DISPOSITION COPIES
❑ AUTHORIZATION FOR FINAL DISPOSITION
This form when signed above by the funeral service licensee (21 a) and by the certifying physician (29 or 32) shall serve as a disposal-transi'
permit for the remains of the decedent named hereon.
❑ ALTERNATIVE AUTHORIZATION FOR FINAL DISPOSITION
This form when completed and signed below by the funeral service licensee shall serve as a disposal -transit permit for the remains of the
decedent named hereon.
I have contacted Dr.
date 10/16/2003 and time 1020
and the doctor has agreed to sign a certification of caus of de th as on s possible.
FUNERAL SERVICE LICENSEE SIGNATURE
License # C0-3139
INSTRUCTIONS: THE PERSON IN CHARGE OF THE PLACE OF FINAL DISPOSITION SHALL DATE AND SIGN BOTH THE YELLOW AND GREEN COPY
OF THE DISPOSITION FORM. FORWARD THE YELLOW COPY TO THE REGISTRAR OF THE COUNTY WHERE DEATH OCCURRED WITHIN 10 DAYS
AFTER THE DATE OF FINAL DISPOSITION. THE GREEN COPY WILL BER AlNED BY THE CEMETERY OR CREMATORY.
DATE OF DISPOSITION 16 0 3 SEXTON'S SIGNATURE
THIS COPY TO BE RETAINED BY THE PERSON IN CHARGE OF THE PLACE OF FINAL- DISPOSITION
CEMETERY CREMATORY COPY a5 -2 -Rev (3/00>