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Reg, Oist. No. 31 Ohio Department of Health


VITAL STATISTICS
Primary Reg. Dist. No. 3101
State File No.
-CERTIFICATE OF DEATH
Registrar's No. 3/0/ - Type or print in permanent blue or black ink
1.Decedent's Legal Name(lndude 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 Numbei 5a. Age 5b. Under 1 Year 5c. Under 1 day 6. Date of Birth(Mo/Day/Year) 7. Birthplace(City and State or Foreign Country)
(Years) Months Days Hours I Minutes
234-56-8867 October 07, 1937 WHEELING, WEST VIRGINIA
72
8a. Residence State 8b. County 8c. City or Town

KENTUCKY BOONE UNION


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

ALFRED L PATRICK VIRGINIA MILLER


17a. Informant's Name 17b. Relationship to Decedent 17c. Mailing Address (Street 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 I8d. County of Death
GOOD SAMARITAN HOSPITAL CINCINNATI, OH 45220 HAMILTON
be or Other Agenl 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


ace of Disposition (Name of Cemetery, Cremalory, or other place) 22d. Location (City/Town and Slate) 7830 HAMILTON AVENUE
MT. CALVARY CEMETERY WHEELING, WV MOUNT HEALTHY, OH 45231
24. Date Filed

JAN 6 2010
25a. Name of Person Is^ying Burial Permit 25b. District No. 25c. Date Burial Permit Issued

JONES, CAMILLE 3101 December 24, 2009


26a. Certifier [5(] Certifying Physician
(Check only one)
Td the best of my knowledge, death occurred at Ihe ttme. date, and place; and due to the cause(s) and manner slated.

Q Coroner
On ihe basis of examination and/or investigation, in my opinion, death occurred at the time, date, and place; and due to the causo(s) and manner stalei

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

No
26e. Signature anfl Tiljj 26f, License number 26g. Date Signed

^
27. Name (Last. First. Middla) and Addr^ Completed Cause of Death
35.068701 1-6-10

WILLIAM L. STAFFORD^ SOUTH LOOP EDGEWOOD, KY 41017


28. Parti.' SnKiar'lh'fl disease, injuries, or complications thai caused the death,"bo not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure, List Approximate Interval
only one cause on each line. Type or print In permanent blue or black ink. Between Onset and Death
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
[cause.
c. Due to (or as Consequence of)
I Enter Underlying Cause
((Disease or injury thai Factor V Leiden Heterozygositv Life
[initiated events resulting d. Due to (or as Consequence of)
I in a death)

Pirt II. Other significant condriions contributing to death but not resulting ti flying cause glv
29a. Was An Autopsy 29b. Were Autopsy Findings
Performed? Available Prior To Completion Of
Cause of Death?

History of DVT's, Diverticulosis QYes DNo D Not Applicable


30. Did Tobacco Use Contribute to Death? 3J. If Female, Pregnancy Status 32. Manner of Death
Nat pregnant within past year 8f Natural Homicide
□ Yes □ Unknown Pregnant at time of death
Not pregnant, but pregnant within 42 days of death □ Accident Pending Investigation

g$ 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
33b. Time of Injury 33c. Place of Injury {e.g., Decedent's home, construction site, restaurant, wooded area) 33d. Injury at Work?
33a. Date of Injury (Mo/Day/Year)

□ Yes □ No

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

33f. Describe How Injury Occurred: 33g. H Transportation Injury, Specify:


rjDriver/Operator Q]Pedestrian QPassenger
[]Other:
HEA 2724 Rev. 01(07

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