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. "; -� STATE OF FLORIDA N *... ,.t 4 • - 4 OFFICE of VITAL STATISTICS ~ 5 CERTIFIED COPY /---2 \ renew atANE FLORIDA CERTIFICATE OF DEATH �� ,.( e LOCAL FILE NO. 1. DECEDENTS NAME (Fist y y e. Lest S4Unq 2 SEX Sandra E. Sweeney F ema l e _ 3. DATE OF BIRTH plbeal, Dry y 4a A �r Mann 44 TINDER 1 YF � s k R DAY s 5. DATE OF DEATH (Mont My Y es/ ) ths January 11, 1949 62 May 27, 2011 6. SOCIAL SECURITY NUMBER 7. BIRTHPLACE (Gay end Sae. //Foreign Caa SY) 6. cowry OF DEATH = y . 200-44 -7906 I Battle Creek, Michigan I Pasco �''° - 9. PLACE OF DEATH - (Clrack�'one) H OSPITAL � YpWerd _ Errnergerncy RoamlOupeTiae _ Dead On Arrival _ NON- HOSPITAL 7f Hospice Fealty - Nuking Home/Long Ten/ Care Fay - Decedent's Hans _ Oles ISpeo7y) 10. FACILITY NAME DI not insilWion, gem sheaf address) 11e. CRY, TOWN, OR LOCATION OF DEATH 11b. INSIDE CITY LIMITS? ° Gulfside Center for Hospice Care I Zephyrhills _Y X No w 12. MARITAL STATUS (Specify) 13. SURVNNG SPOUSES NAME (role, 9.. swab. rams) - O MMbtl - termed, but see.... - Wi0owed - DNad _H 'threw Michael Sweeney ,: Y Q 14e. RESIDENCE - STATE 140. COUNTY 14c CITY, TOWN, OR LOCATION W Florida Pasco Zephyrhills - D 14d STREET AND NUMBER . ZIP CODE 14g. INSIDE C TY mars? - 5053 17th Street I 14e. APT. NO. 14 33542 I X Y.s _N, :::".";('' ' EII 15e. DECEDENTS USUAL OCCUPATION Mora. type of *Mr drane during most of noting Yk) 1 1510. KIND OF SSI91OUSTRY D Oe° t eae Own H ome W Hom emaker J 16. DECEDENT'S RACE (Specify Ills race/races il a c e s d r a l e war dsoeda t considered hiaeemtwaw to be. Moe t ram an one ra may be swiftest) & X Whet _ Black or African American _ Amnon Inten or Alaskan /NAM (Spay bee) - = OU - Anew Indian Chase F;*io _Japanese _ Korean _ Viealmness _ Otter Asian (Specify) m Neeve Hawaean _ Guerorien a Chemono _Samoan - Other Paci is Id (Speak) _ Omar (Sperry) {'�` ° 17. DECEDENT OF HISPANIC/HAITIAN ORIGIN? _Ye Yes, X No _ Yesic0n _ PkrM Rican _Cobs. - CerrairSWAMrrinn , I- Ma* /decedent was aItaspanicorHaaen Origin.) Y1 - Z - Oar/ ilrpa0C (Sway) -Halton 2 18 DECEDENTS EDUCATION (Specify is MacleaY highest dogma at level dWgo ksnpleled at erne d derh. ) 1A WAS DECEDENT EVER N '....!..s _ tfm er Ina Wpm a(dk/r Wi no dpbrea X Feyk 0010 I diderna a GED U.S. ARMED FORCES? `. o - Oa■9s 10w m deQee Cortege dpree (Spar): Assocae _ BaalNOfs _ Maslefs _ Doelarae vas x No Z 20. FATHERS NAME (Fir/. M/dde, Last. SW16q 21. M ONERS NA (Pit. M41lR Heid Sranarr _ -. _ Walter M. Reilly Mary Ruth Martin d 22a INFORMAN NAME 2210. RELATIONSHIP TO DECEDENT 23a. INFORMANTS MAIUNG - STATE Michael Sweeney Husband Florida ° 236. CITY OR TOWN 23o STREET ADDRESS 23d. ZIP CODE . .:; w Zephyrhills I 5053 17th Street 33542 s 7 24. PLACE OF DISPOSITION (Name ofcem. ak; oemalory, or Lew plra) 25a LOCATION - STATE 2510. LOCATION - CITY OR TOWN w Palm State Crematory Florida Clearwater 0 (1) 26a METHOD OF DSPOSMON - B„ fr .. 1 Emanrnasnt X Crrnwan _ DrsnaTirn _ Removal F Stale _ 061 Or (speryy, Q 2610. IF CREMATION. DONATION OR BURIAL AT SEA, 27a LICENSE NUMBER (atLiceneas) 276. SIGMA SERVICE LICENSEE OR PERSON ACTING AS SUCH - W APPROVAL ALG GRANT TE ED ? 2.C.,,. Yes _ No F0462O1 I ► , 20. NAME OF FUNERAL FACILITY o Whitfield Funeral Home Florida -srATE . 0 m 200. CITY OR TOWN 29c. ESS 2a a. zip C ODE STREET ADDR I § Zephyrhills 5008 Gall Boulevard 33542 ■ w cc O 30. CERTIFIER: X V.I W Certifying g Physician - To The beer o my knowledge, 0eelh marred at me line. Ore en0 piece, aand due b hie cause(s) and manner manner slae0 J is LL (Mock era) _ Medical Examiner On the bests a aaniatim, and// invesageeat in my opiate, deem axlmed at me Time, dale and F. 91a w b tea ausa(s) and manner staled. • � 314 DATE ■ � U • , vvyy�� peatldryyy 32. TIME OF DEATH (24 Pr) 33. MEDICAL EXAMMERS C ASE NUMBER e M t I Ci131 lib' I 2245 ■ _, 34a LICENSE NUMBER for/ Caeia) 344 CERTIFIERS NAME 35. NAME OF ATTENDING PHYSICIAN (V other ban Oatler) - At el ' I� Chris Nussbaum, M.D. . O b 36e. CERTIFIERS - STATE 3 64 CITY OR TOW" 36c. STREET ADDRESS 360_ ZIP CODE > w Florida Zephyrhills 5760 Dean Dairy Road 33542 37. SUBREGiSfRAR - Arson and Date 38.4. 'jG /� /� / REGISTRAR I / g - Le` A, 386. DATE FILED BY r: - i5 o'< Y " Y. i C '.