Death Certificate - Myers, Leonarda_4/13/2012534280
CERTIFICATE OF DEATH
Faco? 10. If Deail� OcwrtM N A Hmptat t0a. tl DeaT OavrtM SaneM�e�e O�b Tlim A Mosplal
❑ Yes � No ❑ Unknwn ❑ InpaSent � Emupmcy Department OuytJem Q DeaG on Mival � Hospice Facairy ❑ DeceOeMS Hqne ❑ Nurs'vg HompAUip(eim Care Fatllry
❑ Ou�erl5peti!yI
5953 W 250 S
ETTA RICHARDS
� BwW O Cremavo� O Dmasm � En:anoman
❑ Remwel From Stas
❑ Omc Isceah):
26.wazCpanuGOntaRM? 2). NameM
❑ Yes � No nni �nr.i a
�B. PaM1 I. Entu TTe Chain Ot EventS - DiseaSes, Injunes. Or CompliW tioin - TTat Ovatty C1u5B0 TTe DeaN. DO Not Enter Tertninal Ev¢n'S
Sucn As CarEiac ArtesL Respva:ay Mest, Or Vm��nwWr FEnOaum W ihout Showing The Etidogy. Do Not Ab WeNata. Enter ONy One Cause On
n w,a. nea nee,�i w,a n N���ry.
ImmW ia;e Cause (Fnal Disease Or Cwki.ion ResWCng In Dra:h) A. CMDIAC ARREST
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SeQUaCiaOy List Contliiiau. It My. Leatling To Tho Cause Listea On 8. ARRYTHMIA
tine A. Enter The UMery+ng Cause (0.sease Or Injury iTat Irv;ia;e0 `�o y• ��
TTe EvmLS ReSUIU�g In Death) Last �.
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❑ Yes ❑ ProOaDry 0 No � Unknoxn
❑ MartlW Q MameC. &n 5lpb3'eE ❑ DiwRM
� W[IO.veO ❑ NewlMirtietl ❑ Un4naM1
47665
LUTTRULL
Yes � No
❑ Yrs � No
Appmumate
In:erval: OisH
To oea�n
❑�anw.we.�v..r� ❑ n.r .�r...ao..n ❑ ruA.w�ann.w+wn.zwr.«cv� I� Nawrai � Homcia ❑ nmaent ❑ Pm6n9 �mesn9a�on
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❑ Yes ❑ No
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f Fam 53395 ATTENTqN ESTATE: The Sotial Sewnry x is �arg repues:etl Ey tNs sa;e agency in omer ro pursue responsiWtiry. Disdosure is volunury an0 Nca wiG �e na peiW ry tm revsai.
NRA-20
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