Death Certificate - Hardiman, Kathy L_12/6/2012Local No
CERTIFICATE OF DEATH - RESUBMIT
e�R No 000000293364
FEMALE
896562
Fatcesi 10.1/ OeaT OccwRO L A MuspW: 10a tl Ov3.l� OCWrteO $aneMr�e O�C T�an A Mtsptal
� Fbspice FapLry � DeaOer.(s Mme ❑ Nursug FlameAm¢Rrm Care FaoLy
Q Yes � No � Un!nown ❑ Inpa�eru O Ema3ency0epa�v�en�0uqx.'mt Q DeaEmMival � O:�c(Speoly)
GIBSON
4082 EAST 950 ROAD SOUTH
�
❑ au�ai � e.e„u�do� O oonaoon O em«ownrn�
❑ aemwa� Rm Sr.e
[] OYIQ ($CGO�Yi
� Yes ❑ No
HAUBST
� MainaO� MamM,BuiSepaate4 ❑ Di+acM
❑ WiOOr.etl ❑ Ne.erMdineO ❑ UnFnwm
❑ Yes � No
LANJ WADE BYELECTRONICSIGNATURE Ir��utiusu
Cause Oi Death (See InsWCtiws AM Ezamplas) qpprndmate
28. Part L Ent� The Cha�n Ot Events - Diseases, Iryuna. Or CanO�'+� - T�at Ovecily Causetl TTe DeaN. Do Not Enter Tertninal Even¢ In:aval: Orset
Sucn As Cartliac Arzes� Resp'vatay Mest, Or Ven�,rmular FibnOanm Nhtnout Showing TTe Eudogy. Do Nd AEGeWate. Enter OMy One Cause On To Deas
A line. Atl0 ACEi4nal Lvfes H Necessary.
ImmeEiata Cause (Fnal Oisease Or CoMitim ResW�ng In Dea:h) A. An'OCARDIAL INFARGTION �
.� ..
SequentlaM �s� Cona'��ims, if My, �eaaing 7o Ttie Cause Lisrea On B' W` �
fineA. En:erTheU�WerlyingCeuse�DiseaseOrlrguryTTatlrvUatetl tl����
TM Even¢ ResN•,vg N OeaN) last �, yq NA
e�u...�w.o
D. NA �
❑ Va ❑ PmCaON � No � Unknown
�,..n.a�...:a.�o.�... ❑ A.e�..u:.,.ac�., ❑ runv-.a.A.s�......�.:o...uo.., I� r+aa,rw � Ha�a�ee ❑ ncdcem ❑ vaimrolmgnsamn
nxan.o,.tiavA.Pwuo.�.tei�e.a.o.a ❑uw..,eA.�.uws.�m.v.�r� ❑SUlotle�CONaNpBeDe:ertrvneE
❑ YPS ❑ No
po.�.�so.w�
JERRY
5: r_�sr_oiz i�m¢ooa.�
9:05-DEC-1:
ZP: Af1'OCARDIAL I�FARCi10�
' Su:a Fortn 53395 p77�MqN ESTATE: Re Sodal Seanry p is bang mpuest4 Oy Ws su:e agenry in mJer lo Gursue responsibliry. Disdosure is vduntary aM Uere vrill Ee rw
NRA-20
(7/OS)
- 1 I . � 1 1 � . . . � � 1 . . 1 1