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DEPARTMENT OF STATE HEALTH SERVICES VITAL STATISTICS UNIT

TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS JAN 23 2015 STATE OF TEXAS CERTIFICATE OF DEATH STATE FILE NUMBER 142-15-0078511 LEGAL NAME OF OECEASEO llndudo N

MOUNTAIN HOME AR MALE APRIL 22 1982 l(Y

"""I 32 I Mo I oa,. 7.ALSECURITYNUMBER 18 ALSTATUSATnMEOFOEATH O Manl8d 9. SURVIVING --......... E'S NAME (II wile, QMI name priDI IO ltrSC maniagul

Ii ... 0

D Wclo- D - l'i,l Na .......... D Unknown !'Ob.APT NU, 1oa. RESIDENCE STREET ADDRESS

. I

IQe. STATE

TEXAS 1

10l.ZIPCOOE

n301

110c. CITY OR TOWN

CONROE

110g. INSIDE CITY LIMITS?

181Yos 0No 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE

MONTGOMERY 11. FATHER'S NAME

WALLACE FRANKLIN STONE JOAN MCGINNIS 13. PlACE OF DEATH (CHECK ONLY ONE)

IF DEATH OCCURRED IN A HOSPrr AL 11F DEATH OCCURRED SOMEWHERE OTHER TJ-W,l A HOSPITAL. O Iopa!- 0 ER.Ou"'"" 0 OOA I O ........ F-v O NuRlnn tm>I l'i,l Decadlol'> tm>o O Otho, (Splcilvl 14.COUNTY OF DEATH

,,s l,;IIYIIVWN, Dt" tlF ...... ,..-..,.;uTYUt.UT.::M:PRECIHCTNOI ,

,e. FACILITYNAME(llnol insllution,QCWSUNIDddrMSS)

MONTGOMERY , CONROE n301 17 INFORMANT"S NAME & RELA' 1 JUMM1IP TO DECEASED

118. MAILlNG ADDRESS OF IN C P Code)

JOHN ALLEN HOSKINS V - SIGNIFICANT OTHER CONROE TX n301 19 METHOD OF DISPOSITION 20. SE Of -..... -..-- u,n,..,... UH -.an.n.n-. 21. 0 &,nal Ctemalmn O Ootultioo ACTING AS SUCH

' - Sec101 _______ _ D Entom""""" o--- CORA LEE MCLEAN ,BY ELECTRONIC SIGNATURE -O au,., 1-1 11 ccc2 ! l..22li'.'a:PLACE:o.sl1Fo,,,,..,.,,S""IT'"ION=1"'11ome="'o1"'com= ... ::cry:c.-::aoma=::::IOIY::::-:,...,=,-::;p1oa1;::!:!,1f-!-2=;_-.-.,.23,-;.......,.""',.T10N,""""1c"';::.,1T;;,:o:::..,::-,-:::-::,-..:,sw;:;,,1,---------lL01

s. MCNUTT BROCK CREMATORY CONROE TX 5paca i 24. NAME OF FUNERAL FACILITY { 25. COMPLETE ADDRESS OF FUNERAL FACILITY (StnNM and Number, Clly, Stnta, Zip CodeJ .5 MCNUTT FUNERAL HOME 1600 PORTER ROAD CONROE, TX 77301 ; 26. CERTIFIER ( only one)

O Co,dying pnpidan-To ,-NS o1 mr i..nowi.dgu, d8illtl DIXUINd "' 10.,. c:.wse(s) and rNtM8I staled. (8l Modal Eaunimd.Jusllcu of ine Puce. On lhu basil OI ard'ot In my opnion, tlCCWNd at Iha time.dale Mid plMat. Id dull ta hi CM&Sl.'(S) ..00 INll'V"1f liuued,

! 27.TURE OF CERTlflER 28. DATE CERTIFIED (rnnHSd-yyyyt ,211. LA-EN::u: NUMBER ,30. TIME OF DEATH(Aclual Of prnumed)

jj WAYNE'L MACK BY ELECTRONIC SIGNATURE JANUARY 22 2015 I 12:14 AM _ 31. PAINTED NAME. ADDRESS OF CERTIAER (SlrHI and Numblll, Clily,Stale.Zip Cadet

,32. TnLE OF CERTIFIER

-::: '-. I i WAYNE L MACK 19380 HWY 105 W. STE 507, MONTGOMERY, TX n356 JP .5 ! 33. PART 1 . ENTER THE CHAIN Of EVENTS - DISEASES, lNJURIES, OR COMPUCATKlNS -THAT OIRECTL Y CAUSED THE DEA TH QQ.lQ! ENTER ;j U TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTfUCULAR ABRIU.ATION wtTHOUT SHOWING THE

Approaimale intorval Onsal to death

I .X ETIOLOGY. 00 NOT AIIBREVIATE. ENTER ONLY ONE CAUSE ON EACH. IMMEDtATE CAUSE (Final i ! x ....... condolion-> a.HANGlNG!.----------------------------:_ i i resuling In dNlh) 0"8 IO (DI U a consaquenc:e af): ti -=i , 5 .Iii .e:

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-

,--

u-

,-

con.equ--

onco--

ol-1:

---------------lisled on tna L Enlar Iha UNOERL YING CAUSE

\ :::::a ----------=---,--------c:------------------in daa!hl LAST Oue lO (or as a con of):

'

i i PAJ If 2. o;;i-., laO' I UI n SfGNIFIC CQN91T19NS CONJRIBUJINO ffi PEA TH BUT NOT RESULTING IN THE UNDERLYING 34 WAS AN AUTOPSY PERFORMED? 181Yus 0No l f CAUSE GIVEN IN PART L

'; 35. WERE AUTOPSY FINDINGS AVAILABl..E TO COMPLETE THE CAUSE OF DEATH?

0,Yes ONo 36. MANNER OF DEATH 37 Dill TOBACCO USE l.,Uf'I , "'PV' '- 38. IF FEMALE.

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