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L , � �� � � <br /> _—________�_,._.__—__—____—.__"_ _______..__._"—_____.���.._—'_"_"_"_�_..."_.__'_'_'___._"'_'. ' i <br /> It `I f 1 ' ' ' " ! ''' ' I 1 1 1 ' 1' I� � <br /> � �� OFFICE of VITAL STATISTICS <br /> � � <br /> - CERTIFICATION O�F DEATH - <br /> STATE FILE NUMBER: 2013049514 DATE ISSUED:April 9,2013 , <br /> DECEDENT INFORMATION STATE FILE DATE:April 9,2013 <br /> NAME. i(ATHIEEN BRUNSON - <br /> , <br /> DATE OF DEATH: April 5,2013 SEX. FEMALE SSN: 297-20-6877 , AGE: 087 YEARS <br /> DATE OF BIRTH: September 6,1925 BIRTHPLACE. UNKNOWN <br /> PIACE OF DEATH:HOSPICE <br /> � FACILITY NAME OR STREET ADDRESS.GULFSIDE CENTER FOR HOSPICE CARE � <br /> IOCATION OF DEATH:ZEPHYRHILLS,PASCO COUNTY <br /> SURVIVING SPOUSE,DECEDENT'S RESIDENCE AND HISTORY INFORMATION - <br /> MARITAL STATUS: WIDOWED <br /> SPOUSE:NONE I <br /> RESIDENCE.7270 QMEGA COURT,ZEPHYRHILLS,FLORIDA 33540,UNITED STATES COUNTY�pASCO i <br /> OCCUPATION,INDUSTRY� HOMEMAKER,OWN HOME <br /> �CE. XVuhita BlackaAiricanAmerican Asienlndian _C�uiese _Ftlipx�o NativeHawaiian _Japanese _KOrean <br /> Amersan InEian w Alaakan Nelive—Tribe� Yetnamese Other Aaien <br /> �Guamian w Chamorro _Samaan _Other Pecific Icl: �Ottwr , _Unknown <br /> ' HISPANIC OR HAITIAN ORIGINI NO,NOT OF HISPANIC/HAITIAN ORIGIN <br /> ED'UCATION:HIGH SCHOOL GRADUATE OR GED EVER IN U.S.ARMED FORCES?NQ; I <br /> PARENTS/►ND INFORMANT INFORMATION � <br /> FATHER: UNKNOWN UNKNOWN <br /> MOTHER: UNKNOWN UNKNOWN <br /> INFORMANT�OANN STEEN <br /> RELATIONSHIP TO DECEDENT EXECUTOR <br /> INFORMANTS ADDRESS:49d03 LINCOLN AVE,ZEPHYRHILLS,FLORIDA 33542,UNITED STATES , � - <br /> PLACE OF DISPOSITION AND FUNERAL FACILITY INFOI�MATION � <br /> PLACE OF DISPOSITION:CREMATION CENTER <br /> DADE CITY,FLORIDA <br /> METHOD OF DISPOSITION:CREMATION <br /> FUNERAL DIRECTOR/IICENSE NUMBER: LINDSEY A.PALMER, F042218 � <br /> FUNERAL FACIUTY� HODGES FAMILY FUNERAL NOME-ZEPHYRHILLS F040699 <br /> , 36327 US HWY 54 WEST,ZEPHYRHILLS,FLORIDA 33541 <br /> � CERTIFIER INFORMATION <br /> TYPE OF CERTIFIER:CERTIFYING PHYSICIAN MEDICAI EXAMINER CASE NUMBER: NOT APPLICABLE <br /> TIME OF DEATH(24 hr): 0028 <br /> CERTIFIER'S NAME. SUJANI AKKINENI <br /> CERTIFIER'S LICENSE NUMBER: ME107752 , � <br /> NAME OF ATTENDING PMYSICIAN(If other than Certifier): NOT APPLICABLE <br /> CAUSE OF DEATH AND INJURY INFORMATION ' <br /> PROBABLE MANNEl7 OF DEATH: NATURAL <br /> CAUSE OF DEATH-PART I- and Approximate Interval: Onset to Death: � <br /> a END STAGE COPD " <br /> b FAlLURE TO THRIVE <br /> , <br /> c <br /> ' I <br /> .,. <br /> d <br /> PART II-Other signiTicant conditions contributing to death but not resulting in the underlying cause given in PART I: <br /> ATRIAL FIBRILLATION I <br /> AUTOPSY PERFORMED?NO AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH7 <br /> DATE OF SURGERY• DID TOBACCO USE CONTRIBUTE TO DEATH?UNKNOWN <br /> REASON FOR SURGERY� <br /> IF FEMALE,WAS SHE PREGNANT WITHIN THE PAST YEAR�NO NOT PREGNANT WITHIN PAST YEAR - <br /> DATE OF�iNJURY� NOT APPLICABLE TIME OF INJURY(24 hr)', �NJURY AT WORK? <br /> LQCATION OF INJURY' � , <br /> DESCRIBE HOW INJURY OCCURRED - <br /> i <br />� <br /> PLACE OF INJURY• `} <br /> IF TRANSPORTATION INJURY,Status of Decedent: Type of Vehicle: - <br /> �G�.�� �.it --_ <br /> J,} ,SWteRegisVar REQ: 2073711767 ,. <br /> TME ABOVE SIGNATURE CEFTIFIES THAT THIS IS A TRUE AND CORRECT COPV OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE <br /> tNF,SrA THIS DOWMENT IS PRINTED OR PHOTOCOPIE�ON SECURITV PApER WITH WATERMARKS OF THE GPEAT <br />�pF AF, WARNING: SEAL OF THE STATE OF FLORI�A DO NOT ACCEPT WITNOUT VERIFVING THE PRESENCE OF THE WATER- --'I <br /> Or. MARKS THE DOCl1MENT FACE CONTAINS A MULTICOLORED BACKGROUND,GOLD EMBOSSED SEAL,AND <br /> �� � TMERMOCHROMICFLTHEBACKCONTAINSSPECIALlINESWITHTEXTTHISDOCUMENTWILLNOTPRO�UCE <br />� . 'u A COLOR COPV 8 i <br />,•��OOOwetW�•�., IIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII�I . DM F�M 1�7(11/17) � •., r�wunno�aern�.n�oF �` _ <br /> � S a � s � a ,. ,. �. _ HEALT � '�� <br />