Death Certificate - Dilbeck, Donna F_7/6/2015 a!��y`r, A>-of\'.Y:ifs��itN �tY tUJjn-
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BUREAU of VITAL:STATISTICS,-.
CERTIFICAT•IONOF°DEATH '
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STATE FILE NUMBER: 2015070055 DATE ISSUED: May 12, 2015
IDECEDENT INFORMATION STATE FILE DATE: May,11, 2015
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NAME: DONNA FAYE DILBECK DATE OF DEATH: May 6, 2015 SEX:: FEMALE AGE: 083 YEARS• DATE OF BIRTH: October 20, 1931 BIRTHPLACE: MILWAUKEE,WISCONSIN,UNITED STATES
PLACE OF DEATH:HOSPICE :1":
• FACILITY NAME OR STREET ADDRESS:E T YORK HAVEN HOSPICE CARE CENTER _ R-''
`¢ LOCATION OF DEATH: GAINESVILLE,ALACHUA COUNTY, 32606 \` i-..
SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION , \ '—'_
' MARITAL STATUS: MARRIED
°` SPOUSE(IF FEMALE,MAIDEN NAME): RICHARD DILBECK • -
,. RESIDENCE:400 NORTH EASTVIEW STREET,FORT BRANCH, INDIANA'47648, UNITED STATES COUNTY:GIBSON
OCCUPATION, INDUSTRY: HOMEMAKER,OWN HOME -
,$'^ , 'RACE: X White _Black w A'riran American _Asian Indian _Chinese _Filipino _Native Hawaiian \Japanese _Korean L.!
�, _American lydianw Alaskan Native—TnEe: _Vietnamese Older Asian:
U - _GUamian w Chamorro _$artwan _Older Pacific HI: _Older: Unknown
HISPANIC OR HAITIAN ORIGIN?NO, NOT OF HISPANIC/HAITIAN ORIGIN
EDUCATION: HIGH SCHOOL GRADUATE OR GED COMPLETED i EVER IN U.S.ARMED FORCES? NO
PARENTS AND INFORMANT INFORMATION
.r . FATHER: LEONARD DEWEY HARVEY -
MOTHER: HELEN STEIN
INFORMANT:RICHARD DILBECK
IT•. ; RELATIONSHIP TO DECEDENT:HUSBAND
INFORMANTS ADDRESS: 400 NORTH`EASTVIEW STREET,FORT BRANCH,INDIANA 47648, UNITED STATES '
PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION
PLACE OF DISPOSITION:WILLIAMS COLONIAL CREMATORY , -•• GAINESVILLE,FLORIDA •
• ' METHOD OF DISPOSITION: CREMATION <
• FUNERAL DIRECTOR/LICENSE NUMBER: MARGARET.E.DICKENS, F043157 O
FUNERAL FACILITY: WILCIAMS-THOMAS FUNERAL HOME-GAINESVILLE F040234 • ` G
404 NORTH MAIN STREET,GAINESVILLE, FLORIDA•32601 : 11
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• CERTIFIER INFORMATION .FLORIDA ' ' -I
TYPE OF CERTIFIER:CERTIFYING PHYSICIAN MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE i rn
TIME OF DEATH(24 hr): 0222 - i m
'r _ ; CERTIFIER'S,NAME:tSTEFANIE BETH LORD . G
- ' CERTIFIER'S LICENSE NUMBER: ME60032 • 0
33
r' NAME OF ATTENDING PHYSICIAN(If other than Certifier): NOT APPLICABLE
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•CAUSE OF DEATH AND INJURY INFORMATION I. D
• MANNER OF DEATH: NATURAL ' - - m
CAUSE OF DEATH-PART I•• and Approximate Interval: Onset to Death: O
a NATURAL CAUSES - UNKNOWN - -
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PART II-Other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
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AUTOPSY PERFORMED? NO AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? I
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I DATE OF SURGERY: -' DID TOBACCO USE CONTRIBUTE TO DEATH? NOT STATED , le--
REASON FOR SURGERY:
IF FEMALE, NOT PREGNANT WITHIN PAST YEAR
F w , DATE OF INJURY: NOT APPLICABLE TIME OF INJURY(24 hr): INJURY AT WORK?
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LOCATION OF INJURY:
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1 - DESCRIBE HOW INJURY OCCURRED: -
PLACE OF INJURY: ''•
tiri. . IF TRANSPORTATION INJURY,Status of Decedent: Type of Vehicle:
ae- 0.9b-lt-3 _bw.i9s-Dab • ,
0--- ��t{� REQ:'2015943425- fem. "' - ,State Registrar 333-
1^ THE ABOVE SIGNATURE CERTIFIES THAT THIS 15 A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN This OFFICE. F
fff�jjjj====ryry�� a THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH WATERMARKS OF THE GREAT IqJ
of THE 511,E WARNING: SEAL OF THE STATE OF FLORIDA DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATER- 1
MARKS.THE DOCUMENT-FACE CONTAINS A MULTICOLORED-BACKGROUND.GOLD EMBOSSED SEAL,AND '
�. , THERMOCHROMIC FL THE BACK CONTAINS SPECIAL LINES WITH TEXT.THIS DOCUMENT WILL NOT PRODUCE
s (� c'. A COLOR COPY. •�
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