Carl Edmund AndersonTYPE OR
Middle Last 2. SEX
3. DATE OF DEATH (Month, Day, ear)
1. DECEDENT'S First
NAME
'Gl
PRINT IN
PERMANENT
d.
Auguat 15, 199;.
4.SOCIALSECURITY NUMBER 5a. AGE -Last Birthday
OREGON DEPARTMENT OF HUMAN RESOURCES
BLACK INK
(Years)
5U - - in t
Mos. Days Hours Mins. Country)
I I iici . tt, �wi
HEALTH DIVISION
EVER IN
I.D. TAG NO.
9a. PLACE OF DEATH (Check only one)
�-
CENTER FOR HEALTH STATISTICS[ 136-
OTHERjo Nursing Home ❑ Decedent's Home ❑ Other (Specify)
❑ ER/Outpatient El
❑ Yes
9b. FACILITY NAME (ll not Institution, give street and number) 9c. CITY, TOWN, OR LOCATION OF DEATH 9d. COUNTY OF DEATH
CERTIFICATE OF DEATH State File Number
10a. DECEDENT'S USUAL OCCUPATION
I ncal File Number
(Give kind of work done during most of working life.
Divorced (Specify)
1-
2-
2
3-
4-
5-
6-
3456
7-
8-
9 -
789
fit
fit
17. FATHER - NAML nrsr Imume a� �„ •••-• __
20a. METHOD OF DISPOSITION ❑Mausoleum 20b. PLACE OF DISPOSITION (Name of cemetery, crematory, or 20c. LOCATION - City or Town, State
other place)
7 Burial ❑ Cremation IlRemoval from State
❑Donation ❑other(specify)- Blida CeMLUrY
21a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR 21b. LICENSE NUMBER 22. NAME, ADDRESS AND ZIP OF FACILITY
PERSON ACTING AS SUCH (Of Licensee)
cy and Steil; 135 NiarIt an;
0298
23: DATE FILED (Month, Day, Year) 24. REGISTRAR'S SIGNATURE
25. DID HOSPITAL REPRESENTATIVE MAKE REQUEST FOR ANATOMICAL GIFT CONSENT?
YES ❑ NO ;,V NIA
1O TO BE COMPLETED BY CERTIFYING PHYSICIAN
27. TIME OF DEATH 28. WAS MEDICAL EXAMINER NOTIFIED?
11 ;:Z0 y M ❑ Yes (I No
29. To the best of my knowledge, death occurred at the time, date, place and
due to the causes) and manner stated.
(Signature)
30_ DATE SIGNED (Mopth, Day, Year)
12
13 34. NAME, TITLE, ADDRESS AND ZIP OF CERTIFIERIMEDICAL EXAMINER (Type or Print)
WAS GIFT MADE?
OYES ONO 9)NIA
TO BE COMPLETED ONLY BY MEDICAL EXAMINER
31a. TIME OF DEATH AD (Month, Day, Year, Hour)
M�31b.�PRONOU�NCED 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 stated.
(Signature)
33. DATE SIGNED (Month, Day, Year) COUNTY
14 D1. $�Y 'Y"s) La` uteab t�h. ili.D.' 34 a °", ked y d� 11v�l.�, ,, t Ba is
35. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
fir, ' a I.U. , ,, w
CONDITIONS � , { �t,
IF ANY '} •.
CHECK APPROPRIATE BOX BELOW...
❑ AUTHORIZATION FOR FINAL DISPOSITION
This form when signed above by the funeral service licensee (21a) and by the certifying physician (29 or 32) shall serve as a disposal -transit per-
mit for the remains of the decedent named hereon.
-EfLTERNATIUE AUTHORIZATION FOR FINAL DISPOSITION
This form when completed and signed below by the funeral service licensee shall serve as jspo5altransil permit for the remains of the
decedent named hereon.
have contacted Dr.On dateJ and time
and the doctor has agreed to sign lacertifEca ion f the cause f death as p "slbte.
FUNERAL SERVICE LICENSEE SIGNATURE'S
12
DATE OF DISPOSITION b SEXTON'S SIGNATURE
THIS COPY TO BE RETAINED BY THE PERSON IN CHARGE OF THE PLACE OF FI L DISPOSITION
Middle Last 2. SEX
3. DATE OF DEATH (Month, Day, ear)
1. DECEDENT'S First
NAME
'Gl
6si SXd "DEKSOA I C'
d.
Auguat 15, 199;.
4.SOCIALSECURITY NUMBER 5a. AGE -Last Birthday
5b. Under 1 Year 5c. Under 1 Day 6.BIRTHPLACE (Ci ty and State or Foreign
7. DATE OF BIRTH (Month, Day, Year)
(Years)
5U - - in t
Mos. Days Hours Mins. Country)
I I iici . tt, �wi
September 9, 1911
EVER IN
9a. PLACE OF DEATH (Check only one)
8.WAS DECEDENT
U.S. ARMED FORCES?- HOSPITAL
10 No ❑ Inpatient
OTHERjo Nursing Home ❑ Decedent's Home ❑ Other (Specify)
❑ ER/Outpatient El
❑ Yes
9b. FACILITY NAME (ll not Institution, give street and number) 9c. CITY, TOWN, OR LOCATION OF DEATH 9d. COUNTY OF DEATH
10a. DECEDENT'S USUAL OCCUPATION
10b. KIND OF BUSINESS/INDUSTRY 11. MARITAL STATUS - Married, 12. SPOUSE (If Married, Widowed)
Never Married, Widowed,
(Give kind of work done during most of working life.
Divorced (Specify)
Do not use retired.)
Soil, C JI/- `V L 0,r .
US GoVerr. "-11L Harried Yvol no
13a. RESIDENCE - STATE 131). COUNTY
CITY, TOWN OR LOCATION 13d. STREET AND NUMBER
yalmill I
To.
Hicuinalville I goo 14. ifill Road i333
13e. INSIDE CITY 13f. ZIP CODE 14. WAS DECEDENT OF HISPANIC ORIGIN? 15. RACE American Indian, 16. DECEDENT'S EDUCATION
(Specify No or Yes - If yes, specify Cuban, Black, While, etc. (Specify) (Specify only highest grade completed)
LIMITS?
Mexican,
Puerto Rican, etc.) t No ❑Yes Elementary/Secondary (0-12) College (1-4 or 5+)
DO Specify:
Yes El No �.l.ar
White 4
.__..__ .....� .• _. _:,,.,,,. ....,�,ao,. 14. INFORMANT - NAME and relationship to deceased
17. FATHER - NAML nrsr Imume a� �„ •••-• __
20a. METHOD OF DISPOSITION ❑Mausoleum 20b. PLACE OF DISPOSITION (Name of cemetery, crematory, or 20c. LOCATION - City or Town, State
other place)
7 Burial ❑ Cremation IlRemoval from State
❑Donation ❑other(specify)- Blida CeMLUrY
21a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR 21b. LICENSE NUMBER 22. NAME, ADDRESS AND ZIP OF FACILITY
PERSON ACTING AS SUCH (Of Licensee)
cy and Steil; 135 NiarIt an;
0298
23: DATE FILED (Month, Day, Year) 24. REGISTRAR'S SIGNATURE
25. DID HOSPITAL REPRESENTATIVE MAKE REQUEST FOR ANATOMICAL GIFT CONSENT?
YES ❑ NO ;,V NIA
1O TO BE COMPLETED BY CERTIFYING PHYSICIAN
27. TIME OF DEATH 28. WAS MEDICAL EXAMINER NOTIFIED?
11 ;:Z0 y M ❑ Yes (I No
29. To the best of my knowledge, death occurred at the time, date, place and
due to the causes) and manner stated.
(Signature)
30_ DATE SIGNED (Mopth, Day, Year)
12
13 34. NAME, TITLE, ADDRESS AND ZIP OF CERTIFIERIMEDICAL EXAMINER (Type or Print)
WAS GIFT MADE?
OYES ONO 9)NIA
TO BE COMPLETED ONLY BY MEDICAL EXAMINER
31a. TIME OF DEATH AD (Month, Day, Year, Hour)
M�31b.�PRONOU�NCED 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 stated.
(Signature)
33. DATE SIGNED (Month, Day, Year) COUNTY
14 D1. $�Y 'Y"s) La` uteab t�h. ili.D.' 34 a °", ked y d� 11v�l.�, ,, t Ba is
35. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
fir, ' a I.U. , ,, w
CONDITIONS � , { �t,
IF ANY '} •.
CHECK APPROPRIATE BOX BELOW...
❑ AUTHORIZATION FOR FINAL DISPOSITION
This form when signed above by the funeral service licensee (21a) and by the certifying physician (29 or 32) shall serve as a disposal -transit per-
mit for the remains of the decedent named hereon.
-EfLTERNATIUE AUTHORIZATION FOR FINAL DISPOSITION
This form when completed and signed below by the funeral service licensee shall serve as jspo5altransil permit for the remains of the
decedent named hereon.
have contacted Dr.On dateJ and time
and the doctor has agreed to sign lacertifEca ion f the cause f death as p "slbte.
FUNERAL SERVICE LICENSEE SIGNATURE'S
12
DATE OF DISPOSITION b SEXTON'S SIGNATURE
THIS COPY TO BE RETAINED BY THE PERSON IN CHARGE OF THE PLACE OF FI L DISPOSITION