Document yb29kyj61V9j3GvOBrGQD8m3D

(MDH laze MMiinnnneessoottaa RReeggiissttrraattiioonn && CCeerrttiiffiiccaattiioonn ((MMRR&&CC)) DDooccuummenetnatattiioonn ooff DDeeaatthh Deceased Name (First, Middle, Last, Suffix) prow Date of Death para Date of Birth WMO VTYYwY MM DD YYYY Q Unknown Age (in years) Prior to First Marriage =Sex Swe O Male Sree O Female O Unknown Also Known As Soc Sey om Social Security Number | onrw Ounnm O None O Unknown Under 1 Year aca O Not Obtainable Under 1 Day MM DD YYYY months days hours minutes wos erm Birth Country [O Som mo sass O Born in the United States State/Province Cit dTown Haus Sect O Not U.S. Specify S ueizoun O Unknown Bocas: Readers RE Cr [ooo Romie Zo Deceased's Residence Address Us wis O U.S. Address State/Province County City/Town Street & Number, Zip Code o Fason ous O Foreign country O veka O Unknown Erion (Re TT Education (highest completed) S tran heidoe 03.ANAS) Ser O Unknown ongrdecoss Bachar eo 03.5836885) | O 8th grade or less 0 602mg"n oto Oats de 05, HAMS NE, | Untn [TO Toy O 9th - 12th grade; no diploma 0 ton septaotr GeED comptes ry O High School graduate or GED completed O Associate degree (e.g. AA,AS) O Bachelor's degree (e.g., BA,AB, BS) O Master's degree (e.g., MA, MS, MEng, Med, MSW, MBA) Ever In Armed Forces? O Yes O No O Unknown Deceased's Usual Occupation Kind of Business or Industry Same oan cot bt dare Oct9. 4D.005, ow. O Some college credit but no degree O Doctorate (e.g., MD, DDS, DVM, or gn fee 5 To BT Face Hispanic Origin oto Spanahispanctanro. [Junta areothEto npr Tbe] tte Howat O No, Not Spanish/Hispanic/Latino Race [] White O Unknown [] American Indian or Alaska Native Name of the Enrolled or Principal Tribe Pacific Islander [] Native Hawaiian YouHogan rom Ban Avcasamaican somo O Yes, Hispanic Origin Known African African/American [] Samoan 0Mes econ rin, [sacks rion [J Warn Ta J uamananor [] Mexican, Mexican American, oa I Emepn 0 Sto [Jpciniodan Coron rare Chicano Bae IG rer [toon Howes vommn 0]ome pace [] Puerto Rican Bo BGEoaDn. Sa Cro wy Toner Sony [] Cuban BF HEE Bel Then [] Other, specify proms Soucy Dlomern Oto rr Spy O Unknown if Spanish/Hispanic/Latino [] Black/African American [] Ethiopian [] Liberian [] Ghanian [] Other African Specify [] Kenyan [] Sudanese [] Nigerian [] Somali Asian []Asian Indian []Chinese []Filipino [] Japanese [] Other Asian Specify [] Korean [] Vietnamese [] Hmong [] Cambodian [] Laotian ] Guamanian or Charrorro [] Other Pacific Islander Specify [] Other Race Specify St TD race ame Fr rE Marital Status at time of Death S ariadO evr aries. Wes O Married O Never Married Dros Union Otek amt O Divorced O Unknown OWidowed Spouse's Name O Not Obtainable (First, Middle) Last Name Prior to First Marriage [CO Inside City Limits? ove O Yes i O No Father's Name (First, Middle, Last, Suffix) Mother's Name (First, Middle, Suffix) Last Name Prior to First Marriage Informant's Name (First, Middle, Last or Institution) Relationship to Deceased Address (Street & Number, City, State, Zip) Frocrarowam Place of Death [ Hospital Opens OInpatient Emons Racetptint OEmergency Room/Outpatient Souimarval ODead on Arrival Sernse Other than a Hospital Hospi O Hospice ung boron mcr O Nursing home/Long term care Owain. O Deceased's home Sone O Other Cony County Focity Nom nd Arn eaaro Go Sn 20) Facility Name and Address (Street & Number, City, State, Zip) Physician/ME Providing Cause of Death Information (First, Middle, Last) Funeral Home/Other Institution, Estab. # Funeral Director Name (First, Middle, Last) License # Title EE Method of Disposition Disposition Facility - Cemetery O Burial O Cremation O Donation O = Entombment ORemoval from State/Province State State/Province OOther (Specify) City/Town = = City/Town --| "TThhee iinnffoorrmmaattiioonn oonn tthhiiss ffoorrmmiissccoorrrreecctt ttoo tthhee bbeessttooffmmyy kknnoowwlleeddggee Sonate Signature Exhibit 3530 oweDate Fom #0103 Fab20r Form # D103 Feb/2013 cSot~tr~ ~ eM~non, e2s7.~vV,i ~.~8~~ 33553300..00000011 1i DH ys D E PJtl~ TM EIg'l" OF H E.SLTH Deceased Name (First, Middle, Last, Suffix) MMiinnnneessoottaa RReeggiissttrraattiioonn&& CCeerrttiiffiiccaattiioonn ((MMRR&&CC)) PPhhyyssiicciiaann // MMeeddiiccaall EExxaammiinneerr CCaauussee ooff DDeeaatthh WWoorrkksshheeeett Also Known As Physician/Medical Examiner providing this information Title License # Date of Birth Date of Death Time of Death MM DD YYY Y Was the Medical Examiner Contacted? O Yes MM DD O No Did INJURY or TRAUMA contribute to the cause of death? O Yes sr If Yes, please explain: Is there any reason to postpone final disposition? If Yes, please explain: O Yes YYY Y Date last saw deceased: O No 0 No Cause of Death Part I Enter the chain of events-diseases, injuries, or complications that directly caused death. Do not enter terminal events such as cardiac arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause per line. Add additional lines if necessary. IMMEDIATE CAUSE Een. (final disease or condition resulting in a. 2death) re Sequentially list Ei lecleoaadndidinnitggiotntoos,tthhifeeany, >b. immediate cause. Enter the UNDERLYING CAUSE SEEve, (disease or injury that C. ---- Due to (or as a consequence of) E-- Due to (or as a consequence of) a---- initiated events resulting in death) Due to (or as a consequence of) LAST d. Part II Other significant conditions contributing to death but not resulting in the underlying cause given in Part I Approximate interval: Onset to death Nas an autopsy performed? :)id Tobacco use contribute to :leath? O Yes O No O Probably O Unknown O Yes O No pe Rest rae oobeap ve rs es I Autopsy Results Available to complete the cause of death? Oven One O Yes O No If Female Manner of Death O Natural O Not pregnant within past year O Accident O Pregnant at time of death O Suicide O Not pregnant, but pregnant within 42 days of death O Homicide O Not pregnant, but pregnant 43 days to 1 year before death Pending Investigation O Unknown if pregnant within the past year Could not be determined :)ate of Injury ---------------- MMMMDDDD YYYYYYYY EE Complete Injury Information below if Manner of Death is not Natural Time of Injury _-- Injury at Work? O YYeess If Transportation Injury, specify O Other - specify O Driver/Operator O PPeeddeessttrriiaann O 0AAMM OoPPMM _OOMMiiilittaarryy O NNoo O PPaasssseennggeerr Place of Injury (e.g., Deceased's home, construction site, restaurant, wooded area) _ocation of Injury (Street & Number, Apt. #, City or Town, State, Zip Code) :)escribe How Injury Occurred `CCoommpplleetteedd bbyy:: SSigignnaattuurree 33553300..00000022 DaDtatee FFoorrmm ## DD110022 DDeecc/22001133