William Thomas Wilkinson, Sr.TYPE/PRINT
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93.
9b.
9d.
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Pronouncl
Physician
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m a. Definition
I h1�R�i�IW �3Pfl�� �aiiF3 I�
` RUQ QAPY OF THE RECO,
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GQUNTY H_ LT DE
PAR
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JUL 0 z 2002
COUNTY RE(-16TWI
STATE OF SOUTH CAROLINA
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
STATE BIRTH NUMBER CERTIFICATE OF DEATH
STATE FILE NUMBER
DECEDENTS NAME First -
A4iddl0 Last
SEX
DATE OF DEATH (Month, Day, Year)
L '. -
- `- '� - zp
omas
2.
SOCIAL SECURITY NUMBER
AGE - Last Birthday (Years)
UNDER 1 YEAR
UN3.
DER 1 DAY
DATE Of BIRTH (Mo, Day, Year)URN-,
IRTHPLACE (!ty, and State or Poreign
Z LL
Runt Route Number, City or Town, Slate) -
Months I Days
Hours I MinutesI_h
30e 301
untry)
CERTIFIER CERTIFYING PHYSICIAN (Physician certifying cause of death) ❑ MEDICAL EXAMINER ❑ CORONER
m
v
....hind In death)
(Check only one) _- -
r ❑ PRONOUNCING AND CERTIFYING PHYSICIAN (Physician. both pronouncing death and certifying to cause of death)
-
Nebvasha
WA EOE TEV R IN U.S. ARMED
N
__ - _ -ga. PUCE
OF DEATH (Check only onR' see mshucoons o o ecside) - -_ -
FORCES? or No)
DATE SIGNED omh, y, Year) -
HOSPITAL, _ - _ -
_-
--
Sequentially list conditions, if
_OTHER::
_-- Inpaliem ❑ ER/Outpatient ❑ DOA - ❑-Nursing Home. ❑ Residence ❑ Other -
S
33b.
(Specify)
FACILITY NAME ill not institution, sive .Leet and number) - - -
CtN. TOWN, OR LOCATION OF DEATH
COUNTY OF DEATH
gb ,
. - - _ -. -_
100-
9d.
MARITAL STA US •Marded, Never
SURVIVING SPOUSE P! wilAgive maiden name)
DECEDENTS USUAL IOCCUPATION (Give kind or work done during
KIND OF BUSINESS/1N STRY
Marded, Widowed, Divorced (Spacifyj=
- =_
most o%worklng life: Do net us. retired.)
I
12b.
12a.
12b. -
lira
RESIDENCE - STATE
COUNTY-
CIN, TO`NN,.OR LOCATION
STREET, AND NUMBER - -'
INSIDE CITY UMITS7
._._..
(Yes or No)
1
13b._-
i
13c. lipli
13d.
LP CODE
Was Decedent of Nlapanie Origin? (Specify Yes or No - It yes, specify Cuban,
RACE - American Indian, Black DECEDENTS E`OUCATION (Speciy only highest grade completed)
114.
Mexican, Puerto Rican, It cp. .. _ _ _
White, eta (Specify) Elementary/Secondary(0-12) I College (1.4 or 5+)
❑ Yes. . No
6-In16.
FATHER'S NAME First
Middle "� '^". Leel :
NAME , First. Middle Widen Surname
- 17.
Tyr
J!AOTHER'S
1&
INFORMANTS NAME (Type/Pring
MAILING ADDRESS (Street and Number or Rural Route Number. City or Town, State, Zip Code)
11"Willigm T Willcimcin
_
-6,49 14ni-hni-ijew Pnintg ChjIjin SC 791111A --
METHOD OF DISPOSITION:PLACE
OF DISPOSITION (Name of cemetery, crematory, or other place) I
LOCATION • (City of Town, Stale) - -`
Burial Q Cremation ❑ Removal from State -
20a. E3Donation O OtherS i
( Pec fy)
20t, --. r .' •, r
,0.
2GC. -
FUNE DIRECTOR OR PERSONA TING AS SUCH.(Signetdre)-FUNERAL
DIR. UCEN N
NAMEANDADDRESSOFFACWTY. ❑CENS UMBER Iaf facility)
2
21b, 2199
Caughman-Harman Funei d Home 122b. 231
503 N Lillie Di -
r
EMBALMER (Signe
EMBALMER LICENSE NO.
21
21 c- 11110- ' i- -'
lid.
22a,- --
ng Compiete Items 23a -n only when certifying
To the best of my knowledge, death occurred at the time. date, and place stated.
LICENSE NUMBER
DATE SIGNED (Month, Day, Year)
physician Is not available at time of death
to
cenity, cause of death.
23a. Signature and TWO bi - _
23b. -
23c.
TIME OF DEATH
DATE PRONOUNCED DEAD (Month, Day, Year)
WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER?(yes or No)
1704
24.
M -
25.: 06-29-2002
20. - - -
m On Older
27. PART I. Enter the diseases, inludeA or complicit ns that caused the death -Do -not enter the mode of dying, as cardiac or respiratory arrest, shock, or heart failure, list only one cause''Appp
�p
O m side
DETERMINING CAUSE OF pEATH? (Yes or No)
on each )in..
M
HCuT4�- �t�ocARDiA 1M9A4e7_j0,/
E�
E
INJURY OCCURRED -
IMMEDIATE CAUSE (Final rss�
-:a.
El Accident Investigation - -: 30a 30b. M sec. 30d.
Z LL
Runt Route Number, City or Town, Slate) -
disease or condition
_ _-, DUE TO IOR ASA NSEOUENCE OF):
30e 301
CERTIFIER CERTIFYING PHYSICIAN (Physician certifying cause of death) ❑ MEDICAL EXAMINER ❑ CORONER
m
v
....hind In death)
(Check only one) _- -
r ❑ PRONOUNCING AND CERTIFYING PHYSICIAN (Physician. both pronouncing death and certifying to cause of death)
-
I
3t, -
N
32. eOIl
b.
LICENSE NUMBER
DATE SIGNED omh, y, Year) -
12a.
t
Sequentially list conditions, if
�J �7
�
DUE TO (OR AS A CONSEQUENCE OF):
33b.
Y
33c.
FJ
any, leading to immediate
-
. - - _ -. -_
c . cause, Enter UNDERLYING
CAUSE (disease or Injury -
that initialed events
a
- DUE TO (OR AS A CONSEQUENCE OF:
I
12b.
o
U
resulting lndeath)LAST=-
_-
d.
-
J
N
13a.
13b
0 0
a N
c
m
13c. o 0
v
PART II. Omer significant conditions contributing to death but not resultNo ing In the underlying cause given In Pan I.
AUTOPSY (Yes or No) IF YES, WERE AUTOPSY FINDINGS CONSIDERED IN
•
DETERMINING CAUSE OF pEATH? (Yes or No)
29. MANNER OF DEATH URY AT WORK7 bE
DATE OF INJURY Month, Da , YearJ TIME OF INJURYJINJ
( ySCRIBE NOW
INJURY OCCURRED -
- - (Yes or No)
�Natural 13 Pending - -
- -
El Accident Investigation - -: 30a 30b. M sec. 30d.
❑ Suicide❑ Could not PLACE OF INJURY • Nome, Farm, Street Factory, Office, LOCATION (Street and Number or
Runt Route Number, City or Town, Slate) -
be Determined etc.)(Speci(y)
❑ Homicide I
30e 301
CERTIFIER CERTIFYING PHYSICIAN (Physician certifying cause of death) ❑ MEDICAL EXAMINER ❑ CORONER
NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
(Check only one) _- -
r ❑ PRONOUNCING AND CERTIFYING PHYSICIAN (Physician. both pronouncing death and certifying to cause of death)
-
-
Dr. Leon Khoury -
3t, -
32. eOIl
SIGNATURE AND TITLE OF CERTIFIER best of my know) e, eaN occurred at the time, date and place, and due to the -
LICENSE NUMBER
DATE SIGNED omh, y, Year) -
cause(s) and manner ae stated. _ - _
-
- -/ /• Xv1 _ _
�V /
�J �7
�
J3a.®
33b.
Y
33c.
1� O NAME AND ADDRESS OF PERSON WHO N 33a. (Typo
/
30e. REGISTRARS SIGNATURE
35. IN. L �,
{ DHEC 670
Rev. 1990
DATE F ( onth, Day. Yearl„
36.-
to