Death Certificate - Spain, Willard_4/19/2013 •
COMMONWEALTH OF VIRGINIA
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•
ERTIFIED COPY OF DEATH RECORD . - •
COMMONWEALTH OF VIRGINIA - CERTIFICATE OF DEATH
COPY A DEPARTMENT OF HEALTH•DIVISION OF VITAL RECORDS-RICHMOND
REa6RU:lON.___ CER:Y'%GTE STATE FILE
f-0RDMCORDS AREA NUMBER /5 COJ (NUMBER NUMBER
VITAL RECORDS -
V,''
` DECEDENT I.FULL NAME
OF DECEDENT:.
Dm° _ DAN
(MORO PM/ a SEX I ode
-.F.
-
WILLARD W. SPAIN
3'. a.DATE OF (ma) (day) Rem/ a.AGE I_ IF UNDER 1 YEAR IF UNDER I DAY s DATE OF ® ❑
-- DEATH ___ Ina) ION teem) B.WAS O FORCE'. p
BIRTH
EVER w V S T°
i I mviw •••• 1 Mars � rtaz a' a AFY.c'D FCFCEB)�I ❑
inn RS rya L
PLACE OF NAME OF HOSPITAL OR INSTITUTION OF DEATH(a none,a steel 1 Oct Pat. a.COUNTY O:DEATH (TI L�egeNeni ciy,law tlany
DEATH I DOA Ewer Rm FY:en1
• Community MemoriaL Healthcenter; ❑ ❑ [ Mecklenburg
II.CITY OR TOWN OF DEATH warm coy re Gan FmO? W.STREET ADDRESS OR RT.NO.OF PLACE OF DEATH
y 0' ❑ 125 Buena Vista Circle
SrnTth Hill r•
: USUAL 11.STATE(OR FOREIGN COUNTRY)OF DECOEN:S RESDENCE 12 COUNTY OF DECEDENTS RESIDENCE (Iindepe not cay,:eae Mini)
RESIDENCE
OF DECEDENT . '
' Indiana
Gibson
11 are OR TOWN OF RESIDENCE - - wpaV my or at Imes Il STREET ADDRESS OR RT,NO.OF RESIDENCE I CP CODE
es - I
=x Princeton fX ❑ 1101 E. Water Street : 47670
_ o PERSONAL 15.NAME OF DECEDENTS FATHER IA MAIDEN NAME OF DECEDENT'S MOTHER
DATA OF .
_ E DECEDENT
Ray Spain Emma Spain .
•
17.FACE OF DECEDENT 11'B.OF WSEMIIG ORIGIN/ U sea,pcSy LLbn.Marian. 18 EOUCATp%(Biee Y only NLAac made ewVMeA
Punic Rican.etc.
White I - .>a. ❑ Yes EbwenurylS cnoary iDla 1 0 caMS:N+ds•)
A.CITIZEN OF WHAT COUNTRY 21.BIRTHPLACE Wane w=entry) }2 NEVER MARRIED❑ DIVORCED❑ D.IF HARRIED OR Vaoo-LEO.NAME OF SPOUSE
_ y _ (JdraaaIZR.WInk)
cc�� U. Se 'A. Indiana MARRIED WIDOWED❑ Velma Horrall Spain
21:
Custodian Maintenanre Wife
iT •°e CAUSE OF DEATH - m.PART L Ems the chasm.ejt=Ax or m,yt�vsSal caused the death.Do na ester the nude cyvy.such as a-Tac ce resp'etay wrest.Sbck,or bean sn, Iafi Jx BETW_u
uE let s'Ty av omeme TFU. A`D DEATH
a:E VMEDUTE CAUSE(-rIF L
o g` TO PHY51(}<N: mfCMl resulting n hem •NI DUE TO(OR AS A CON:SSEE..J OFF I1���•f c Complete
co c66 v SelwWay c n..En .tl M:Y.I IDI(I(s
sic,HavSc'al a AUSS O muse.Enter UNDERLYING DUE TO A Cp5ECUENCE OF);
ce ct 20)cn CAUSEIOimaa>h In DM LAST...ab:.MM8 6 den)LAST - G ....G 4-.4-/J,-�
K ✓✓W
azmaOiaFWa 36i AIROPB'll Yes e9
AUDpRCEO_Y'
• 1521. — a.IF FEMALE,WAS THERE A PRE TTLVCY Mc.F EXTERNAL CAUSE IT WAS 2N.DESCRIBE HOW INJURY RELATING TO DEATH OCCURRED
= CI PASS MONTHS? rammO emoiieawwcO -
cc
tu�- A'OiEi
❑ ro❑ w ❑ O X�6o m
Pam rnt 2N,TIME OF INJURY (IM.) lay) (yew) ffi INJURY OCCURRED 1
ye l atttod,0t Mg.PUCE OF INJURY I`cwe,tarn, ba,Way a town) (av✓yl IcsD<)
Lab N Pn1 o
Waxy. ante[Ip3_MC. I
and redly AY. tNe
ar nt ants S P.M. Y.rxa ❑ M ❑ - I
em—TPle. n m I�r •�
'�' To DIM test
raY- eaiARC:iNS-
�• t eon We em and Pam an b'F..We camels)sYC
ACTUAL Jo ^Ta1.TE SIGNED:
SIGNATUTiE I'
nsx„ m2 I / 51-LS-03
NAME• T • NG PHYSCIA N(roe or PraW AADDRESS OF ATTENOVC e`Y """"Af/ .
,4L( £ ina2£,J0 in I f?L Ai / ' At Sr.7I/lt
FUNERAL a. BURIAL REMOVAL rEFMATp.I PI . (nine a cemetery or amatory) WW1 Or yI Ia+l
DIRECTOR OF BURIAL ,
❑ n -
REMOVAL.ETC. Indiana
Decker Cemetery Patoka n
31, I •.daWrat C:PC Cs'aeem IFTEj ESR ' . ' NAME a FUNERAL
to T1 1 HOME AND
Crowder-Hite-Crews
ADO'FSS:
is • L.• a • B i1 VA
REGISTRAR
Eli ( , »I II, i' I _ '8 i -03
RESERVED FOR cilST;-
REGISTRAR'S USE: ..",#
f
Th is is to emfy thrai th�is n true and correct repr dilation of the original record filed with the •
Medle bu-r°-CowfliHeaithDeparhnen: Bovdt n, irginia. - -
t ^
I C / ;u. )/ / 1
r c u ITr ey .e J Dntelssed: ee7 _
,s iy 5 rr ' � ,'trsr : { Registrar or Depty st A-v' o
AIV REPRODL CTIOt--bF---THIS DOCUMENT IS PROHIBITED BY SEATUTE. DO NOT ACCEPT
, f,.r
17iVLESS'LTIBEARST rwJ fPRESSED SEAL OF THE MECKLENBURG COUNTYDEPARTMERNT
OF HEART✓H-G'L'E_ARbleAFFITXED.
- i tYSX�T3.'iarat'0T�
Section 32.1-272, Code of Virginia.as amended - -
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