Death Certificate - Campbell, Brenda Ellen_6/1/2005��b.�s� �'.'�� �` CITY OF FORT WORTH; TEXAS �� F=���'�"`�
�.'+�%-' VITAL STATISTICS DIVISION �� e�"�=pr��
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j STATE OF TEXAS CERTIFICATE OF DEATH. '_` srqre Fi�e NUMaea �
I. NAME OF DECEASED (a) FIFST (E)lAIODLE (c) tAST (0) MAIDEtJ 2. SE% J. DATE OF DEATH I
u Brenda Ellen Campbell : i�. B�own Female December 10, 2002 �
F'�j� a. DATE OF BIRiH 5. AGE IF UNOEF t YR IF UNDER 1 OAY 6. BIRTH PIACE (CITY 8 STATE Ofl FOftEIGN COUtfTpy) 7. SOCIAL SECURITY NO. +
' pNYFARS) MO DAYS HOURS MIN
� Juty 25, 1947 55 Oakland City Indiana
,
m OF HISPANIC ORIGIH4 RICPN, ETC.� U.S. ARMED PORCES7 COMPLETED, ELEM. OR SECANDq{�V � I
Caucasian �yES �NO ❑YES �NO (��Z)COLLEGE(1346,t7.) l2 �
� 12. MARRAL STATUS 13. SURVIVING SPOUSE pF YnFE GIVE MAIOEN NnME) 14y, DEGEDEt7PS USUAL OCCUPATION 1a0. KIND OF BUSINESS OB INDUSTRY
� MARRIED ❑NEVERMARRIE� � !
_ � vnooweo ❑o�voaceo Walter Campbell : Homemaker Own Home �
d i5a. PESIDENCE STFEE7 ADORESS
� ' "'" "' "' ' 15b. QTY OR TOVlN
m' 1700 Brookarbor Court Arlington �
I 15c.CWNN ISd.STATE . 15e.ZIPCODE � 151.INSIDECfiYLLNITS, C
� Tarrant Texas ` ' - "` 76018 [7� res ❑ "o � j
= 16. FAiHER'S NAME f 7. MOTHER'S MAIDEN NAME � �
o Fred Brown :`,:" `� r Edna Mullins �
�- 1B. PLACE OF DEATH ICHECK ONLY ONE - !
C
G HOSPRAL: � INPATIEM � EWOUTPATIENT � DOq p7}{ER:. ❑ NURSING HOME. ❑ RESIDENCE ( Fl� HOS ice House .. .. ='
E � . . ,.,_�OTHEfl SPEq
f9.CAUNIYOFDEATH 211.GfiY.09i�N';lpFpJlSDEGiYlINfS.G�.'EPP.���i:Y1J ,t.h:,M`cOF1iOSP:Tn! OAII.'SIPJTICY!(Il:wtinl�xliL(p�,sbwitr¢efe0tlress)..... .� �
m , y .
d Tarrant Fo�Y b"J-v1h - 'Eriary Cilgz Hospic2 House �
0 22.INFORMAN7-SIGNANFE 8 REtATIONSHIP 23, MAILPlG ADDRESS OF INFORlAANT 1
N
° Walter Cam bell Husband :: � 1700 Brookarbor Arlington, TX 76018 y
� 2a. METHOD OF DISPOSRION 25a PIACE OF �ISPoSIipN puYp pccEUETEav, 250. ..... .�. p9. Wy,�E 8 ADDRESS OF FUNEflAL HONE � �
CHEMAiOPY OP OiHEP RACEJ �p�
DFV�/ Cremato ---
❑ euav,� Z6.LOGATiON�CRY,STATE) � '�. �0d` � � Mid-Cities Funeral Home �
.,!/(J: � '" - �, v . =->; : ' 0
fxl caenurwr, . Fort Worth TeXas" [� g' `,;v ';','�
❑REMOVAIFROtASTATE p�_SIGNAT EOFUNRAl01RECTOROflPERSON•�/n' y.� ti_-- S�OF)AIfPORF(E0W2Y I'
❑ DONATION ACTI UC L� dy . .., U^�'�'� � ta"` � p
J � ' f O ii ( z& �ATE OF DISPOSITIONr �., '
` ❑ on{ea�saecir� !, � � 'Haltom City, TX 76117
� ,. � ::- a 12` 12-2002�`�� p
a. 30.CERTIFlER \/ a(;� `G' 'Y;��, ..`J� � ��"� ^�
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'°' �'X� CERTiFYWG PHYSICIAN TO TNE BEST OF `.tY K::O::` 0.. � DEATH C J'ir.EDAi� dE TME, DATE, AND PIPCE, AftD CUE, O T:E CAUSE�S) AhD MA::F.[!1 p5 STATED.
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a _ J -. ,
' m ❑ MEDICAL EXAMWER � \" � ; � �
1 ON THE eAS15 OF E%AMINATION ANO/OR INVESTIGATION, IN MY.OPINION, DEATH OCCU� ED AT` TT1E TIlf.E, DA7E, PIACE, AND DUE TO THE
i
� � ❑ JUSPCE OF THE PEACE'J CAUSE(SJ AND MANNEH AS STATEO."" --'�,, /� 3� �� t `( �
avi i�.�f -Ti�"` !"i � x���~ 1 .. �..to t- r �.., 1t? s: i'�i Ij
a 31. SIGNATUqE b TfTLE OF CERTIFlER '� �': h. " '- �-.• 32. DATE SIGNED �.
°'a { � 4��'y, � 33.TI.NEOFOEATH �
c � KWNtl�Yt4Y (n'sw!/w v1T� !�i i`�. i) f' "x,�s'�'� rao onr�l yEw ,i
T 3a. PRWTED NAME E ADORESS' F CEHTIFIER '- . r -" 2"'� ^� �� 1 � L 12:45 P. M.
c ° Y � �: ,p3:,_ 4 � " - (`• ' N !�_ .' . �
g�, K2thleen Crowley, M.D. l� ;""' 1325 Pennsylvania Ave,�Sude 450 Fort Wo,rth�T� 76104 � �
.,, 6
_� 3a PAflT 1 EMER THE DISEASES, 61JURIES ORCOMPIICATpNS iHAT.CAUSED THE DEATH DO NOT ENTER THE MODE OF OYING SUCH A$ Appvrimare {'
�++ ? CAADIAG Ofl RESPIRATOHV ARREST; SHOCK OR H 't
- EARLFAILURE. LISTONLYONECAUSEOMEACHLWE. �� WemalBeMreen �
� - I \ � �l . �j�^ ,; . .::1" � f Ome� artl Deaili �
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y- � IeaCugtoirtm�a:ecausa.En;er � ��_ ' /\ -.�� . . �
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� PART2 OTHEflSIGNIFICANTCpNOfTIONSCONiRIBUTWGTODEAiHBUTNOTflESULTWGW7F1EUN0EfiLYWG 36aAU70PSY7 36b.AlfrOPSYFWDINGSAVAILA6LE �c
�' � CAUSE GiVEY I.N?Aq, t;.o., �ywr.e adce, r]-e_�sxs, ktp Y) .. -.� � � _ . �. PqIOR TO CAMPLETIpN OF CAUSE OF ' �
uo . % ' � • `: ��:i� ° ..� .. DEATHP- ' � :.
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6 O . k . � ❑ YES �O ❑ YE$ � ` � �`P
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F n 37. DID TOBACCO USE CONTRI6UTE TO DEATH 3B. DID ALCAHOL USE CONTRIBUTE TO DEATH 39. WAS OECEDENT PREGNAN� f;
❑ YES ❑ PROBABLY ❑ YES :❑ PFOBABLY t
� NO ❑ UNNNOYM ND -. _ �� AT TIldE OF DEATH ❑ YES QNO ❑ UNK �Y�'
� O UNKNOYIN ' . , WITqIN VST f2 M0 ❑ YES �ND ❑UNK � � %.
40.MANNEROFDEATH aIa.DATEOFINJUftY 4t0.TIMEOFINJVFY a1cINJUFYATVlORI( a1d.PUGEOFViNqY-�TNOME,F �'
Aflµ STFlEET, FACTOqY, OFFlCE, �_
�NATURAL ..' r: x-�-: ETC.ISPEGIF'n , f
� i M. � VES; ❑ NO � ' �
❑ACCIOEM . 61e.lOCATION(STREETANDNUTABER,CRYORTO\YN,STATE) -- '"�� .` �
m ❑ SUICIDE � - . _ � � � � 6
m r�
❑HOMICIDE 611.DESCflIBEHOWIWURYOCCURRED . � �; �
> B
W ❑PENDWGNNESTI..ATON � � . � �
Q
N [] COUID NOT BE DETERMINED �
,^-. dPa. flEGISTRAR FILE NO. a2b. DATE RECENEO BY LOCAL REGISTAAR -� 42c SIGNANRE OF LOCAL flEGISTFiAfl � �� �
> 0 2 614 6 D EC �3 0 2002 `'' � '��-�. �G��� �
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LF321227 � �
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o This is to cerlify that this is a tme and correct reproduction of Ihe onginal record as recorded in this office. Issued �m�
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