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Death Certificate - Simmons, Curt A_7/3/2017 PC+'—s ta4A)A_A ` '1?i, , •J"r' 'tit STATE OF FLORIDA. - nftt "li}t '`�t:&9 rrt.1' AP'r/Zf��_ • ti �:.�. r x r� c I W _ r ° o 1°•° ^6t° . ° • `EUREAU'>'of 'VITAL° STATISTICS*° ° os;° ° , ° 7_ -,; c.1 C. 1 O f .O // G °. ° ..,S/ O o ,l ' Y' O'f�H ° Joto.t 4 O O 0 V ° '• O. , off° o ° 0 , �e1 {•o. ° uTerl ' ° t [ f{.(!p o ° o o TOjo., 1 <�AMENDED: lb:. ° 0° y°a' • CERTIFI:CATIONPOF�,DEATH o ° ° ° °° , o , °aC0 Qad co- "c t Or - O O 41 'J 4 STATE FILENUMBER: 2016061275ri Janus 5;201'7 ° �� d 4 DATE ISSUED I_ TY - DECEDENT4INFORMATION ,,r • STATE.FILE DATE ApAAA 2P,2016 �TTTr��� ,,,,NAME:;CURT ALLENo,SIMMONS "- • -ao ,.. - i ° . ' 6 .I'I, 4 i Gt h •• /jet :. ..--,� ..,. ... , •.. - AGE 00 YEARS1 rt"� ` �+,r DATE OF BIRTH}- December 6, 1951 .' BIRTHPLACE: NEW CASTLE INDIANA UNITED STATESE PLACE,OF DEATH:'NURSINGG HOMED w�''• �,°;r,..rte ,d°s { a'�° FACILITY�NAME OR:STREET ADDRESS:•HIGHLANDS,CAKE10ENTER - � 9 ° - ', LOCATION OF DEATH LAKELAND POLK'COUNTY 33813 - �# `t SURVIVING SPOUSE;,DECEDENT;S-RESIDENCE'AND HISTORY INFORMATION) _ oO$ MARITALSTATUS,-NEVERMARRIED _ S 1 'ti P I °o ° 8' �''•' SURVIVING S OUSE NAME'r NONE--• p, .• ^ - ti d> r ' i o \r e° _-- rr c "R, ''`� laA. e RESIDENCE 42401LAKELAND HIGHLANDS,ROAD; LAKELAND,.FLORIDA 33813, UNITED STATES o COUNTY P.OLK6 N �! r OCCUPATION INDUSTRY: GEOLOGICAL ENGINEER;.PHOSPHATE._, ° ti o f RACE _1�V`m1 e Black or African Am,erican Asian Indian Chinese 4— Filipino Native Harahan _Japanese Korean, I u o American Indian or Alaswi Nau a Tn°e' 6 ° 4 Vietnamese "Other,Asian. no 7 a Guamanian or Chamorro Samoan Other Pacific IN 9 t4 Other. Unlinadn 4 t HISPANIC OR HAITIANLORIGIN?1NO ,NOT OF HISPANICIHAITIAN•ORIGINI ' 'er ` 6 °"EDUCATION,•MASTERS,DEGREE , co w•�2 EVER'IN'U S ARMED,FORCES?NO G� "" � '" ! '<_ .. 4 ■ARENTS,AND;INFORMANT INFORMATION - ; ° FATHER:- - ' KENNETH' P SIMMONS ,..,i •. a 1 V°• ° ° ` .• MOTHER: TMARY A' JONES' e� 4 } ' , o ,,, , INFORMANT,MARY A SIMMONS,. - - °-: ° F3.) r;RELATIONSHIP TO DECEDENT:MOTHER, _ ' - ° _ -5 . of ° ti _ ,. INFORMANTSADDRESS:.P O-BOX{325 OAKLAND,CITY INDIANA 47660(UNITED STA ES ;1;14-t-v y °6:-.,,, '4r ; t� a PLACE'OF DISPOSITION}AND'FUNERAL.FACILITRYtINFORMATION'.- ` PLACE OF DISPOSITION LAKELANDFUNERAL HOME CREMATORY ' c7o '�� - 1 - a- 'A I . LAKELAND FLORIDA s '` °���fff 0 ' al METHOD'OF DISPOSITION:'CREMATION' "''(( -° �Q °9Q B a O Q FUNERAL DIRECT OR/LICENSE NUMBER: JASON D.HIGGINBOTHAM F0718411 e , 5, /.1 q FUNERAL FACILITY: SLAKE ND FUNERAL HOMEIrF,041331i c,-..gi, ,-`erg,,, - . ,t S', ,�,.apq nl O I 2125 SIBARTOW RD;:LAKECAND�FLORIDA' 33801 l'..,!,- .-• 1 I r 1 T• O � •CERTIFIER INFORMATION . - - o r- W u TYPEtOF CERTIFIER CERTIFYING PHYSICIAN. MEDICAL EXAMINER,CASE NUMBER NOT APPLICABLE CC °o TIME OF DEATH•(24:hr), 1700{.. J ' ' ,f,' ' 'D_ATE CERTIFIED:AppN,20;2016r o- / . RI•I- ^ CERTIFIERS NAME. RICHARD FRANCIS;SWEENEY,JR " a c ' O Q ,� 1 CM1RTIFIER SLICENSE NUMBERME59085 ' � 7 ° . ° m e 0 u. f,�,., NAME OF ATTENDING PHYSICIAN(If other.than Certifier): NOT-APPLICABLE• Y ,,pro g. '., -b m. O CAUSE OF DEATH ANDQNJURY`IINFORMATION, ., .r T^ °`� ,' D ' MANNER OF DEATH: NATURAL--- ,rc, ' ° •r i t J . ° - : co Q e C A U S E OF DEATH-.PART I- and'App oximate interval: Onset to.Death: • ° .c,� 0-00. •° O G a PROBABLE MYOCARDIAL INFARCTION //� 5' - �p >< _ -,t,...4 rY ,,,, * 11 1 ,:411; I k 3D 1 r I `D - e '3.:2(117 F1�F " a6 iLi 4::::::_,...9 `OD ! ©07 - 00'1 �1 zv! GIBS O U oa ,—�f dCOUNI ti DITOR' e : C IPAR�TrII�-�ther,significant conditions•contrabbutinglto dentb,but notIresultir�gin the underlying c uuse'given imPARTI ° • ,.F , AUTOPSY PERFORMED? NO-34° •"AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUoE OF, DEATHS t�t `< DATEIOF.SURGERY:• ��• m DID TOBACCOIU SE•CONTRIBUTE TO DEATH? UNKNOWN . R z S ! REASONrFOR SURGERY. 7- - m�c in I F NOT APPLICABLE. - 4 ,O °o I_ ,,', a. ° d B o° ,.,- O DATEOF INJURY: 'NOT APPLICABLE ' • TIME,OF INJURY(24thr) - INJURY AT WORK?A (r cSi' rLOCATION OFINJURY I ``•' b o .. �� ,t.''- - o r rye'- ,pe° }r: `w }� I I --:' f- `DESCRIBE HOWiIN9l'1RYOCCURRED: y-.�i' r��� I' ` 1 �� '�t" f , I;�y'��I '� 'et y/' y 1 G ° ° I ]w "i 'o ' b JP 4 J PLACE OF INJURY:.t 0. ° n .,. - ,� i ° c'• °t LIFTRANSPORTATIONINJURY,Satus-of Decedent ,? �.'f`° Type.of Vehicle W Q - :0-1B c DATE AMENDED 01105@017 ANY,CERTIFICATION'ISSUED PRIOR TO THE AMENDED DATE MAY BB NULL AND VOIDS �i ` " a, ° +. l o M° o o °W o��0 0 0. • oror la e .2 rr'�//� 51 . c. e I' °p orj� 0 0 0'..0 0 '.t a °.%9'c°"° °, ° ::?:(1,°%. 0 0 © " _ ,State Reg�stra J o o . o: ° o o' REV:. 201769'3733 e o LE. _j / ... t8_ o. •;or =,o of o. ° 0 0 0�p _o �,00- o ,o o •°V _ L THE ABOVE SIGNATUFE CERTIFIES THAT THIS is A TRUE ANOCORRECT COPY OF THE OFF CIAL RECORD ON FILE INTTHIS OF O E? o O 5_ 0 ° 'THIS P'C.IIMENi IS PRINTED,OR PROTocOPIED-ON SECURrrY PAPER WITH WATERAIAR{5 OF THE GREA -r tHE ST. • WATER-0, •, MARKS THE:DOCUMENT,FACE;CONTAINS AIMULT1COLORED BACKGROUND GOLD EMBOSSED SEAL,ANDS ' `1 , is~ 4 , THERMOCHROMIC FL THE BACK CONTAINS SPECIAL LINES w ITH.TEXTFTHIS DOCUMENT\NLLNOT PRODUC $ IAy IYC„ C. ° ACOLOR CAPV. �r ` ° O T'o G'` ° O /• e e\• v o DH FORM 0}13), °c o 0 _ G _ "p ' lillllllllllllllllilllllllllll ° tt "°°�' u;CERTIFICATION OF VITAL RECORD ,,,Le.--.:41 �nTM - TMt4,1f•