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    DEATH CERT JEANpdf

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    DEATH CERT JEANpdf

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    22 views2 pages

    DEATH CERT JEANpdf

    Uploaded by

    spurlock90

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    CER

    BIRTH BER: 0000-030-0000


    NUMBER:
    DECEDENTS NAME- (LAST, FIRST. MIDDLE, SUFFIX)
    BALLARD JEAN a
    02/01/1941 01/12/2012 03:03PM
    SEX SOCIAL SECURITY NUMBER AGE
    PLACE OF BIRTH-(CIY, STATE, COUNTRY)

    66 TIMPSON, TX UNITED STATES

    DECEDl:NT'S ALIAS NAME(S) -(LAST, FIRST, MIDDLE,


    FEMALE 434-76-5275 70 YEARS

    SUFFIX):
    RESIDENCE OF DECEDENT - (STREET ADDRESS, CITY, STATE, ZIP CODE, COUNTRY)
    PARISH/COUNTY
    201 N BOGLE RD #21 LOGANSPORT,LA 71049., UNITED STATES
    YES DESOTO
    EVER IN U.S. ARMED FO.RCES? OCCUPATION
    INDUSTRY OF OCCUPATION

    �AME OF SURVIVJNG SPOUSE (LAST, FIRST, MIDDLE, SUFFIX)


    WIDOWED
    FATHER'S NAME- (LAST, FIRST, MIDDLE, SUFFIX) FATHER'S PLACE OF BIRTH-(CITY, STATE, COUNTRY)
    AARON RHODES
    MOTHER'S NAME-. (LAST, FIRST, MIDDLE, SUFFIX) MOTHER'S PLACE OF BIRTH-(CITY, STATE,
    AUDREY BEACHUM
    INFORMANT'S NAM. E- {LAST, FIR-ST, MIDDLE, SUFFIX) RELATIONSHIP TO DECEDENT INFORMANT'S ADDRESS

    EDUCATION:
    OF HISPANIC ORIGIN?: NO, NOT SPANISH/HISPANIC/LATINO
    RACE:AFRICAN AMERICAN

    PLACE OF DEATH FACILITY NAME


    SHREVEPORT, LA WILLIS KNIGTON HOSPITAL
    FACILITY ADDRESS-(STREET ADDRESS. CITY, STATE, ZIP CODE, COUNTRY)
    2600 GREENWOOD RD SHREVEPORT LA 71103
    CADDO
    METHOD OF DISPOSITION
    PLACE OF DISPOSITION
    BURIAL
    O.E PRICE MEMORIAL
    PLACE OF DISPOSITION- (CITY, STATE, COUNTRY) PARK
    LOGANSPORT, LA UNITED STATES
    01/19/2012

    ADDRESS OF FUNERAL FAClLITY

    NAME OF FUNERAL DIRECTOR (LAST, FIRST, MIDDLE, SUFFIX)


    LICENSE NUMBER
    MAYENCE,ROBERT EARL EOOOO N

    SIGNATURE OF FUNERAL DIRECTOR DATE


    •e-sign• 0010010000

    MANNER OF DEATH NATURAL

    IF FEMALE? NOT APPLICABLE


    DID TOBACCO USAGE CONTRIBUTE TO DEATH? NO
    PART I. Enter the chain of events-- diseases, injuries, or complications- that directly caused the death. DO NOT enter terminal even� such a
    CA U SE O F cardiac arrest, respiratory arrest, or ventricular fibrillation without showiny the etiology. DO NOT ABBREVIATE.
    -- - - - - . .
    IMMEDIATE CAUSE· " (F.inal dise ase or condition resulting in death) a. AMYOTROPHIC LATERAL SCLEROSIS

    Sequentially list conditions, if any, reading to the cause listed c,n line a. b.

    Enter the UNDERLYING CAUSE (dlsease or injury that initiated the C.


    events resulting in death) LAST ..
    d.

    PART II. Enter other significant conditions contributing to death but not resul
    HYPERTENSION
    WAS AN AUTOPSY. PERFORMED?
    FINDINGS USED IN DETERMINING CAUSE?
    NO
    NOT APPLICABLE
    INJURY INFORMATION PLACE OF INJURY TIME OF INJURY INJURY AT WORK IF
    TRANSPORTATION
    INJURY, SPECIFY:

    LOCATION OF INJURY- (STREET ADDRESS, CITY, STATE, ZIP CODE, COUNTRY) PARISH/COUNTY

    DESCRIBE HOWIN:JURY OCCURED

    I CERTIFY THIS 'CORONER CASE' BASED ON MY EXAMINATION OR INVESTIGATION AND, IN MY OPINION, DEATH OCCURRED Ai:JHE TIME, DATE. AND PLACE,
    AND DUE TO THE CAUSE(S) AND MANNER STATED.
    SIGNATURE OF CERTIFIER: •e-slgn• .• . 01/12/2012

    CERTIFIER NAME - (LAST, FIRST, MIDDLE. SUFFIX) THOMA, TODD GARY


    CERTIFIER TITLE: CORONER
    CERTIFIER ADDRESS -.{$TREET ADDRESS, CITY, STATE, ZIP CODE, COUNTRY)
    HEARNE AVE., SHREVEPORT, LA 00000 UNITED STATES
    0000

    BURIAL TRANSIT PERMLT.

    52213 DESOTO 00/00/0000 00/00/0000 RE


    REGISTRAR SIGNATURE OF REGISTRAR DARLENE W. SNITH •e-sign• CO
    ISSUED BY Black, Lee
    RD
    Issued On: 0010010000 0:00:00 PM
    HE
    STAT
    E OF
    LOUIS
    IANA,
    � PURS
    IFY TH AND CORRECT COPY OF A
    CERTIFI Al: OR DOCUMENr:•REGISTERED Wll.'.H T • UANT
    T
    R.S.40:3
    2,

    �
    �

    .. # ��'\'\'\\�

    * �

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