Death Certificate - Washington, Virginia_3/13/2015 r. Reg.-Dist.No: 18 Ohio Department of Health
L ' .,
• Primary Reg.Dist.No. 1807 VITAL STATISTICS
ry G State File No. 2014093084
'�/y CERTIFICATE OF DEATH .
`� - i.Regl5Var5 M1O�70/L,�jc / L� Type or print in permanent blue or black ink
r"- ' 1.Decedenrs Legal Name(Inctude AKA's if any)(First Middle,LAST.suffix) 2.Sea 3.Date of Death(Mo/Day(Year)
VIRGINIA LEE WASHINGTON Female October 25, 2014
I I I PRINCETON, INDIANA
W8a..Residence State Bo.County 8c.City or Town
t1°f OHIO CUYAHOGA CLEVELAND
s+ a Btl.Street and Number Be.Apt.No. 81.Zipcode 8g.Inside City Limits?
Illa c -,9103 Empire Ave 44108 Yes
9.Ever in US Armed Forces? 10 Surviving Status at Time of Death 11.Sviving Spouse's Name(If wife,give name ono:-to first marriage)
°- No Widowed (and not remarried)
12.Decedent's Education 13.Decedent of Hispanic Origin 14,Decedent's Race
- HIGH SCHOOL GRADUATE OR No Black
GED
' ° 15.Fathers Name 16.Mothers Name(prior to first marriage) -
�� •= HARRY 'GOOCH MILDRED -ROUNDTREE
�m 17a.Informant's Name 1 1 ib.Relationship to Decedent 17c.Mailing Address (Street end Nam:wr,C4y.Slate,Zip Code)
makrwk 00.
_JANALEE"BURRELL BROWN Niece 9103 Empire Ave
18a.Place of Death_ _. ' - - - - - _ _
Decedent's Home CLEVELAND, OHIO 44108
-.18b.Facility Name(If not Institution,give street&number) 18c.City or-Town,State and Zip Code 18d,County of Death
'-9103 Empire Ave CLEVELAND, OH 44108 CUYAHOGA
m
?,.„..4,, 19.Sig e of Fu.-rat Se •ce Licensee or Other Agent 20.License Number(of.licensee) 21.Name and Complete Address of Funeral Facility
.008112 STROWDER FUNERAL HOME
m e .Z 22a.Method of Disposition 220.Date of Disposition
Burial . November 01, 2014
O22c.Place of Disposition(Name of Cemetery.Crematory,or other place) -22d.Location(City/Town and State) 822 E 105TH ST
co Lake View Cemetery CLEVELAND, OH CLEVELAND, OH 44108
, o
23•R istrarsSl lure 24,Date Flied 0 3 201
•
g v Yr, '7 v��f sea
. 25a.Name of Person Issuing Burial Pe t 25b.District No. 25c.Date Burial Renew Issued,
ku IBLECH, MORRY 1800 /(7 ?4 ' 7.1/
26a.Certifier El Certifying Pnysician
(Check only o») To Me beg of my knpdedge.death=three at Be time.pate.and date:W cue t0 The cause(s)and manner state.
-p•. U Coroner
W_ on the tests of eaamtw:ion snow irrestcaben,in my opeuoa death occurred at the time.date.are 11ata;Nn due m me tenets)are manner dated.
u' 26b.Time d o Death 26c.Date Pronounced Dead(Ma/Day/Year) 26d.Was case referred to coroner?
CWC 2:24 P.M. October 25 , 2014 Yes .
O °26e. =and le of Certifier I / 26:.License number 26g.Date Sig 3 //e/
r MD 35.026149
27.-Name(Last,First,Middle)and Address of Person win Completed Cause of Death •
CHRISTIE-RICHARD ERNEST, 4670 RICHMOND'RD SUITE 200 WARRENSVILLE HEIGHTS, OH 44128
28.Pan I. Enter the disease.Nimes,or cpnplkations that caused the death. Do not rivet Be mode of dyig,wen as card=et seswtton arrest.shock.or bean failure.Lip Aporoximate Interval
'only one each one.Type or pun m tmanea wee or watt nit ,. - Between Onset and Death
Immediate Cause t a. _
-
=Aaisoath) t • I `C�v/L6.cc�Yt-Gr-(_ - --- -
q •-
Sequeruialty list b.Due to(or as Consequence of)
conditions.if any.`
•
leading to Immediate •
• cause.
c.Due to(or as Consequence of)
i EreerUndertying Cause
Q (Disease or irµpy that
° initiated events resulting e:Due to(or as Consequence of)
LL it a death)
•
•• • .) Pan a Omer Mond-scant condunru contributing to death but not rebutting in the underlying cause given In Pan I. 29a.Was An Autopsy 29b.Were Autopsy Findings •
Performed?
r-,�� Available Prior To Completion Of
V /j �'7 ^I/ ❑Yes lid't+o Cause of Death?�/ -
d-c pT DYes DNo ❑NOt Applicable
30.Did Tobacco Use Contribute to Death? 31.If emale,Pregnancy Status 32.lyrener of Death
_ _ of pregnant within past year DU Natural ❑ Homicide •
7- ❑Yes I�'Unknown Pregnant at time of death
Not pregnant,but pregnant within 42 days of death ❑Accident ❑ Pending Investigation
• Q No ❑Probably Not pregnant,but pregnant 43 days to 1 year before death
Unknown If pregnant within the past year ❑Suicide ❑ Could not be determined
a a.Date of Injury(Mo/Day/Year) 33b.Time of Injury 33c.Place of Injury(e.g..Decedent's home.construction site,restaurant,wooded area) 33d.Injury at Work?
❑Yes 0 N
33e:Location of Injury(Street and Number or Rural Route Number,City or Town,State]
u.
m., •,• ,t,1 _
m 331.Describe How Injury Occurred: 33g.If Transportation Injury,Specify: -
m
° ['Driver/Operator ['Pedestrian [passenger
. - ❑Other.
° xEA ma aay.euel _., s v _ .
R aO-i.V Ile-3 co - owe (25 �- oar
2&-1 l -It.-3Do -ooD- $(Q-oa / TTd,g
-a6 - d1 - 16 - 30o -too . 8 -Oa ') • FILED
I HEREBY CE91!FY 1Hi3
DOCUMENT IS AN EXACT
COPY OF Tit-RECORD O N FILE V/Ill
- - THE OHIO DEPARTMENT CF FEAL TH. MAR 13 2015,
. H0 -3r.IU:a0 514 S
- . . GIBSON COUNTY AUDITOR
•
_ _ . - MOrtRY A tilt Ll, t REGSTRAP
Girict Oft,ns,,STS?iSllffS •
Pfln:ESRt-' ' 3 SF-fit
. REV.6/2009