Death Certificate - Ivy, Dexter_6/25/2012635015
CERTIFICATE OF DEATH
No 000000258081
Fwcesi 10.1f OWT OKAmCE N � HOSp1dl: 101 tl Ol3.� OtturtlO $OrtKMefe Otlic Tl�ai A Wuplal
❑ Yes � No ❑ UnYno.m ❑ InD�en� O Er.iaBency Depar9�e�t OubaCent 0 DeaO m Pmral ❑ Mmpice Feotty ❑ De¢Cenfs Mame � Nwsvq HarcJLai9��mm Cara FavLry
❑ Oma 15oaM)
663 SOUTH 150 ROAD EAST
19. OtteOenh EOutabn
HIGH SCHOOL GRADUATE OR GED
R��7
� anw O crtma on O oo'uxn O E�:omcman
❑ Ren�wa� Frcm Sute
❑ Oma ISOecifvk
❑ ves � No
❑ MamMO Alaeelea.&n5eparate0 � DIwcM
.� � VMMO ❑ N!'M1YAl3niM ❑ UnkXMI
❑ YGS � NO
�a�sv vr �ea�n �am msvuc�rons Am riemv�m) bGrmdmate
28. Part I. Enter The fl�ain q Events - Diseases, In'rynes. Or Can�cstion - Tliat Dv�y CauseE TTe DeaN. Do Na Enter Temtinal Events In:wal: O�set
Sum As CaMiac Mest ResO��aY �g�. Or VuCnwlar FlDnOaUOn VAttwut SM.ving The Elidogy. Do Not ADOrevia:e. EntM ONy One Ca�e On To DeaN
A line. AOtl AtlOiUnal lines H Neceuary.
ImmeEia:e Cause (Fufal Dis�e Or Cmaiuon Resulung In Deatn) A. �SCHEMIC CARDIOMYOPATHY YEAFtS
.� .
SeQUentiaCyListCOnEP.ms, HMy,LeadingTOTheCaiaelistetlOn B. ATHEROSCLEROTCHEARTDISEASE YEAFtS
tine A. Entu The Untlalying Cause (Oiseasa Or Irgwy That Inua:ed °
The Events Resultvig In DeaM) Las� �
c� .
D.
❑ Yes ❑ P�oCaM' � No � Untnawn I � r.anro�wa..v.ur.. � n.��urw.aa.n ❑ r.vnv+�ann.w��w.�.ranaur� I� NaWrel � NamYqe ❑ Rcd4nt Q Pa�+81mssE9atim
flraewrwsnnw+aom..�rre.e,.o.s� I�lw� Av�+wMin.a�r� ❑SUkkeOCwkNdBC�lbmunlO
NONE
CIXmG
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❑ YCS ❑ NO
��I�1
i3395 p�MqN ESTATE: The Social Sewnry R is beig requateE Ey Nls stale agenry in ortltt to pursua ra5ponv0yry. 0.sCawre 6 wluntary eM Nere w11 De no penelry for r�usai.
NRA-20
(7/OS)