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Reg. Dist. No. 31 Ohio Department of Health

VITAL STATISTICS
Primary Reg. Dist. No. 3101
State File No.
-CERTIFICATE OF DEATH
Registrar's No.
Type or prinl in permanent blue or b.ack ink
1.Decedent's Legal Name(lnclude AKA's if any)(First Middle, LAST, suffix) 2. Sex 3. Date of Death (Mo/Day/Year)
EDWARD ALFRED PATRICK December 23, 2009
Male
4. Social Security Numbe, 5a. Age 5b. Under 1 Year 5c. Under 1 day 6. bate of Birth(Mo/Day/Year) 7. Birthplace(City and State or Foreign Country)
(Years) Months Days Hours Minutes
234-56-8867 October 07, 1937 WHEELING, WEST VIRGINIA
72
6a. Residence State 8b. County Be. City or Town

KENTUCKY BOONE UNION

8d. Street and Number
11322LoftusLane
9. Ever in US Armea Forces?
No
12 Decedent's Education
DOCTORATE DEGREE OR
PROFESSIONAL DEGREE
15. Father's Name
8e. Apt. No. 8f. Zipcode 8g. Inside City Limits?
41091 Yes
10. Marital Status at Time of Death 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Divorced (and not remarried)
13. Decedent of Hispanic Origin 14. Decedent's Race
No White
16- Mother's Name (prior lo first marriage)

ALFRED L PATRICK VIRGINIA MILLER

17a Informant's Name 17b. Relationship to Decedent 17c. Mailing Address (Sireel and Number. City, state, zip Code)

JOHN PATRICK Son 1322 Loftus Lane

18a. Place of Death

Hospital - Inpatient UNION, KENTUCKY 41091

18b. Facility Name (If not Institution, give street & number) 18c. City or Town, State and Zip Code 18d. County of Death
GOOD SAMARITAN HOSPITAL CINCINNATI, OH 45220 HAMILTON
19. Signature o^£iiceral Service ;e or Other Agent 20. License Number (of licensee) 21. Name and Complete Address of Funeral Facility
008159
WALKER FUNERAL HOME
22a. Method of Disposition 22b. Date of Disposition

Removal from State December 26, 2009

:2c. Place of Disposition (Name of Cemetery, Crematory, or other place) 22d- Location (City/Town and State) 7830 HAMILTON AVENUE
MT. CALVARY CEMETERY WHEELING, WV MOUNT HEALTHY, OH 45231
Registrar's Sigi 24. Date Filed

LTCI *" ' -mo JAN 6 2010

25a. Name of Person Issuing Burial Permit 25b. District No. 25c. Date Burial Permit Issued

JONES, CAMILLE 3101 December 24, 2009

26a. Certifier H Certifying Physician
(Check only one)
To tlin best of my knowledge, death occurred at the time, dale, and place: and due to Ibe cause(s) and manner slated.

FJ Coroner
On the basis of examination and/or investigation. In my opinion, death occurred at the time, date, and place; and due lo the cause(s) and manner staled.

26b. Time of Death 26c, Date Pronounced Dead (Mo/Day/Year) 26d. Was case referred to coroner?

No
26e. Signature and Ti 26f. License number 26g. Date Signed

35.068701 1-6-10
I 27. Name (Last, First, Middla) and Addn Completed Cause of Death

WILLIAM L. STAFFORD>?R.; 413 SOUTH LOOP EDGEWOOD, KY 41017

28. Part I. Enter the disease, injuries, or complications thai caused the deaih. Do nol enter ihe mode of dyln c or respiratory arr
only one cause on each line. Type or prinl In permanent blue or black Ink.

Immediate Cause
[Final disease or condition Respiratory Failure
resulting In death]
Aspiration Pneumonia 1 Month
Sequentially list b. Due to (or as Consequence of)
conditions, if any, Late Effects of Stroke 1 Year
leading to immediate
Functional Quadraplegia 2 Years
jcauae.
c. Due to (or as Consequence of)

I Enter Underlying Cause

■ {Disease or injury that Factor V Leiden Heterozvgositv Life
linitiated events resulting d. Due to (or as Consequence of)
I in a death)

Part tl. Other significant conditions contributing to death bui nol resulting in the underlying cause given in Part I. 29a. Was An Autopsy 29b. Ware Autopsy Findings
Performed? Available Prior To Completion Of
Cause of Death?

History of DVT's. Diverticulosis DVes Qno G Not Applicable

30. Did Tobacco Use Contribute to Death? 31. If Female, Pregnancy Status 32. Manner of Death
Not pregnant within past year Hf Natural □ Homicide
□ Yes □ Unknown Pregnant at time of death
Not pregnant, but pregnant within 42 days of death □ Accident □ Pending Investigation
gl No □ Probably Not pregnant, but pregnant 43 days to 1 year before death
□ Suicide □ Could not be determined
Unknown if pregnant within the past year

33a. 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 □ No

33e. Location of Injury (Street and Number or Rural Route Number, City or Town, State)

JM. Describe How Injury Occurred: 33g. If Transportation Injury, Specify:

□Driver/Operator QPedestrian QPassanger
□Other:
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