Death Certificate •
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=¢ �* f - -i CERTIFICATION OF VITAL RECORD., - , "A ,r
A ' ; DEPARTMENT OF STATE HEALTH SERVICES 41�ye ;
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r TEXAS DEPARTMENT OF STATE HEALTH SERVICES-VITAL STATISTICS ~
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Sec)08 2020 142-20-156891
STATE OF TEXAS CERTIFICATE QF DEATH STATE FILE NUMBER
1.LEGAL NAME OF DECEASED(Include AKA's.'any)(FnL ValkLm0 (Before Herbage) 2.DATE OF DEATH- ACTUAL OR PRESUMED ,'`
(mma0-yryy1 -
= RUSSELL ALPH NORUM AUGUST 29,2020 1F
n IF UN R 1 YR IF RIND R 1 DAY 6.BIRTHPLACE(CM A Slam or Foregn Country) �p
+ • 3.SEX 4 DATE OF BIRTH (rren.da-YYYYI 5.AGE-Last Birthday /-TT;
• . CM tam. Men
5 MALE NOVEMBER23,1937 (Yaws) 82 D.rs MINNEAPOLIS.MN !"
7 SOCIAL SECURITY NUMBER 8 MARITAL STATUS AT TIME OF DEATH B.SURVIVING SPOUSES NAME le spade.gnn name once m Na marnagel
a NI Married ❑WMored(out nol remarried) :.
__ � 5 46 REsiDe62 ❑DMviced(bu not... ed) ❑Never Mamed ❑unkrown TERRY BACHTUYET NGUYEN
- IS.
RESIDENCE STREET ADDRESS 10b APT NO 10c.CITY OR TOWN
r C M 14671 PERTHSHIRE RD •
HOUSTON
s�S.+
• M;' - C 104.COUNTY 10e.STATE 10F.ZIP CODE 102.INSIDE CITY LIMITS?
°•M) � HARRIS TEXAS 77079 ®Yes ❑No - .44
• '1
00,
11.FATHER/PARENT 2 NAME PRIOR TO FIRST MARRIAGE 12.MOTHER/PARENT 1 NAME PRIOR TO FIRST MARRAGE
$L'�itt - = r ALPH NORUM HELEN KASPAR
<< i .. _
_ 13.PLACE OF DEATH(CHECK ONLY ONE)
'� IF DEATH OCCURRED IN A HOSPITAL. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: _
-- Tr;:t- , O 0 Irpabent ❑ER/Oulpaeent ❑DOA ❑Hmpm FaoMly 0 Nursing Home 0 Decedent%Home ®Odors(Specify) DAUGHTER RESIDENCE
!e C„ry)N'FY OF DEATH M.CITY/TOWN.ZIP OF OUTSIDE CITY UNITS.GIVE PRECINCT NOl 116.FACILITY NAME Ia n al baes6On,gem sear address)
' g 16317 PINTAIL CT.
g COLLIN PLANO,75024
•4.'1 - 3 17.INFORMANTS NAME 6 RELATIONSHIP TO DECEASED 18.MAILING ADDRESS OF INFORMANT(Slur and Numbr.Cily.StMYZIP lode) Ai
3 77
` FO GALE PEARSON -DAUGHTER 8317 PINTAIL CT.,PLANO,TX 75024
•
19.METHOD OF DISPOSITION 2C SIGNATURE AND LICENSE MA,6ER OF FUNERAL DIRECTOR OR PERSONAOMIG 21. ICI unsnown
❑Burke ®C18matim ❑Donation AS SUCH
❑Evmernwd ❑Rrro.'ham wee 0 µ.,,,p,,,,,,.
JAVIER ANTONIO HERNANDEZ,BY ELECTRONIC
❑Oner Ispec8Y) SIGNATURE-115218 Bloc`
Lot
22.PLACE OF DISPOSITION(Name RI amelery,crematory.other pH.) 23.LOCATION(CMrIm n.and Star)
v',. - 1 ROLLING OAKS CREMATORY COPPELL,TX sp..
24.NAME OF FUNERAL FACILITY 25.COMPLETE ADDRESS OF FUNERAL FACILITY(Steel and Nurror.CIF.Sale.re/Co.)
vJ
TED DICKEY FUNERAL HOME 2128 18TH ST.,PLANO,TX 75074
e26.CERTIFIER(Chedn ores ore)
®CeNyep II'9 anTome earamy bronudJ..MEl oared dwbti ne (el rM nr0 rand
e n Medcr EWnrdJlroa r per Peace-On the errs oImrnrpA raV enasipefa r.m my open'_.err maned s:der kme.der Ind plena.end doe m err came(s)am craw awed.
F.11
27SIsNATURE OF CERTIFIER CO.:DATE CERTIFIED(mmWI-YYYY) 29.LICENSE NUMBER 30.TIME OF DEATH(Acoal or presumed)
c RALPH COX.BY ELECTRONIC SIGNATURE SEPTEMBER 5,2020 G3253 11:30 PM
E a 31.PRINTED NAME.ADDRESS OF CERTIFIER(Steel and Nrnbr,CBY.SEUZII ) 32 TITLE OF CERTIFIER
i a RALPH COX 4343 N JOSEY LN,CARROLLTON,TX 75010 MD
* ..04:.
o g. 33.PART 1.ENTER THE CHAIN OF EVENTS-DISEASES.INJURIES.OR COMPLICATIONS-THAT DIRECTLY CAUSED THE DEATH. DO NOT ENTER Appoyimre idanral
3 F TEWARIAL EVENTS SUCH AS CARDIAC ARREST,RESPIRATORY ARREST.OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE 00501 n aMN
€ ETIOLOGY.DO NOT SUCH ENTER ONLY ONE CAUSE ON EACH.
IMMEDIATE CAUSE IFeal
C I WsanrconcO.-> s METASTATIC CARCINOMA OF THE BLADDER UNKNOWN _
a1 W
Doe m(«u•mnsequerpe of).
O Sepseayblmn E
MYd do lne a Enar Ha :J ...
„ 1 i W Duen1«Nemrr.,eNusnn all: r
w (D 11110ERLYINI'CAUSE
`%< < r i 7 (dnsaaae«ivory dal
s-- U named the events restating y
_�L'z g in- death)LAST Due to(or W sea nre'RAwnu pp
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.PART 2.ENTER OTHER SIGNIFICANT CONDITION AT_H S CONTRIBUTING TD O. BUT NOT RESULTING IN THE UNDERLYING 34.WAS AN AUTOPSY PERFORMED?
D2 e CAUSE GNEN N PART I ❑Yes ®No
= 35.WERE AUTOPSY FB J18 MP DNGS AVAi1E TO COMPLETE 1:
C/a/SE OF SDEATH?0
Os ❑Yw ❑No
•• - C) MANNER
36 MAER OF DEATH 37.DID TOBACCO USE CONTRIBUTE 38 IF FEMIALE. 30.IF TRANSPORTATION INJURY.SPECIFY:
�� ®Natural TO DEATH' ❑Not M prevent Mew past mar
: 00 0 YA❑Pregnant Alal time dea8, O
H Passenger •'
0 Stn.e 0 No ❑Na peg9nt,NA pregnant within 42 days at death ElPeOeslnan
0 AM•n 0 Pfe"i011t' ❑Nol pregnant but pregnant 43 days m DIM Mar before death ❑Ohm(Seemly)
❑Prndn'n're9gaea^ 0 Probably 0 Unknown,1 pregnant warn me oast yea.
0 Cored not be delenne,ed ®Unknown
�'♦ M 40a.DATE OF INJURYInen4d-yyyy) 400 TIME OF INJURY 40c INJURY AT WORK,400 PLACE OF INJURY H e.g.Decedemb home.cons/FictionW.restaurant wooded.wood areal
iii ,
H :- N- Dr. ❑No
uD 3fJ.. _ 8 40e.LOCATION(Street and Number.City.SNeleZp Code) 401.COUNTY OF INJURY
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_ - ¢ W 41.DESCRIBE HOW INJURY OCCURRED /
N JON .�
Al - 42a.REGISTRAR FILE NO. 42b.DATE RECEIVED BY LOCAL REGISTRAR 42c.REGISTRAR
L�ff I(fllll rrrrr•C r ir�,,i'����-'' EDR NUMBER 00044d44814540 L,II''N rrweec ATE-"'ty =_1,
.':'• . I .S, 1+ OF This is a true and correct copy of the record as registered in the State of Texas. Issued under the 1(A` OF ---- F� •f
° `�55`'� �v. - authority of Section 191.051, Health and Safety Code. `k�'S' _yc�cE�r ,^ ��
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_ ISSUED Sep082020 TARADAS `ul ! r�b�i• y `'
_ 5 STATE REGISTRAR 5 W '1:. �_ ' 2F 55H5A WARNING:THIS DOCUMENT HAS A DARK BLUE BORDER AND A COLORED BACKGROUND n "�• ��i�
t- �� ' * ,II - -- - -- T4.n"ti-t1# 'IL STATISH`III"
-•".: !••,,riir r»yyIIII, r ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE r��ru I I d