HomeMy WebLinkAboutL_Death Certificate_20180326_v1CERTIFICATE of DEATH
CERTIFICATE NUMBER: 2017.024827
FIRST AND MIDDLE NAME(S): ALEXANDER MUIR
LAST NAME(S): HENRY
COUNTY OF DEATH: KING
DATE OF DEATH`. MAY 29, 2017
HOUR OF DEATH: 02:15 PM
SEX: MALE AGE: 81 YEARS
SOCIAL SECURITY NUMBER: 538-30-4035
HISPANIC ORIGIN: NO, NOT SPANISHIHISPANICILATINO
RACE: WHITE
BIRTHDATE: JULY 01, 1935
BIRTHPLACE: RENTON, KING COUNTY, WASHINGTON
MARITAL STATUS: DIVORCED
SPOUSE: NOT APPLICABLE
OCCUPATION: TRUCK DRIVER
INDUSTRY: BEVERAGE
EDUCATION: HIGH SCHOOL GRADUATE OR GED COMPLETED
US ARMED FORCES:. NO
•INFORMANT: PATRICIA HENRY
RELATIONSHIP: DAUGHTER
ADDRESS: 13727 156TH -AVE SE RENTON, WA 98059-6747
CAUSE OF DEATH:
A: CHRONIC OBSTRUCTIVE PULMONARY DISEASE
INTERVAL: UNKNOWN
B:
INTERVAL:
C:
INTERVAL:
D:
INTERVAL:
OTHER CONDITIONS CONTRIBUTING TO DEATH:
DATE OF INJURY:
HOUR OF INJURY: UNKNOWN
INJURY AT WORK: UNKNOWN
PLACE OF INJURY:
LOCATION OF INJURY:
CITY, STATE, ZIP:
COUNTY:
DESCRIBE HOW INJURY OCCURRED:
IF TRANSPORTATION INJURY, SPECIFY: NOT APPLICABLE
DATE ISSUED;' 06106IW017
FEE NUMBER: 1706052
PLACE OF DEATH: HOSPITAL
FACILITY OR ADDRESS: VALLEY MEDICAL CENTER
CITY, STATE, ZIP: RENTON, WASHINGTON 98055
RESIDENCE STREET: 13727 156TH AVE SE
CITY, STATE, ZIP: RENTON, WASHINGTON 98059-6747
INSIDE CITY LIMITS: YES COUNTY: KING
TRIBAL RESERVATION: NOT APPLICABLE
LENGTH OF TIME AT RESIDENCE: 58 YEARS
FATHER/PARENT: WILLIAM JOHN HENRY
MOTHER/PARENT: FAITH ADELINE QUI,NCY
METHOD OF DISPOSITION: CREMATION
PLACE OF DISPOSITION: CADY CREMATION SERVICES
CITY, STATE: KENT, WASHINGTON
DISPOSITION DATE: JUNE 05, 2017
FUNERAL FACILITY: CADY CREMATION SERVICES
ADDRESS: 8418 SOUTH 222ND ST
CITY, STATE, ZIP: KENT, WASHINGTON 98031
FUNERAL DIRECTOR: DAVID SCOTT QUILICI
MANNER OF DEATH: NATURAL
AUTOPSY: NO
WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE
CAUSE OF DEATH: NOT APPLICABLE
DID TOBACCO USE CONTRIBUTE TO DEATH: YES
PREGNANCY STATUS IF FEMALE: NO RESPONSE
CERTIFIER NAME: DOMINICA TOULOUSE, MD
TITLE: PHYSICIAN
CERTIFIER ADDRESS: 4011 TALBOT RD S #440
CITY, STATE, ZIP: RENTON, WASHINGTON 98055
DATE SIGNED: MAY 31, 2017
CASE REFERRED TO ME/CORONER NO
FILE NUMBER: NOT APPLICABLE
ATTENDING PHYSICIAN. NOT APPLICABLE
LOCAL DEPUTY REGISTRAR: DIANE BOGAN
DATE RECEIVED: JUNE 0.5,2017_
Affidavit for Correction Mail to: Center for Healltih Statistics
P,0, Box 47814
OPHealth This is a iegal dricurnem. Col! piete In ink and do not alter. 01,/mpia: VVA 38504-781A
360-236-4300
STATE OFFICE USE ONLY
Ufnber mber
information On recori:"I
Record 'Fype: El sirih El )a)oa,6, El ililarriage
1. Name on Record: Date o, Event--
3. P4ce of Event:
IT
A Father/Parent Full Legal 'game (Spouse A, for Marriage Or Dissolution)
i5- Mother/Parent Full Birth Name (Spouse 3 for Marriage or Dissolution)
(D
13. Mame of Person Raquesting Correction: Relationship to Lj Self Guardian 01 Informant El Hospital
Person on Record: 0 Pai,ent(si El Funeral Director n Other (specify)
7. Return NlailingAddiress:
Telephone Number
rmall Address:
Use, the se�,-flon belovi for ro2iiesting any cOanl ges On 91 rec.ord. lh��, rocord is incort -ect or incomplete as follows:
The record nolij shiu?vs:
The true fact is:
is.
9.
110.
11.
12.
i:1
14.-
I dleclar& under Penalty of Periury under hhe iaws, Of Erie S -tate 0-1 Washing"wn that the forgoling is true and correct
16a. Signature: 116b- Signature of Zo parent (if required):
PHne(T name:
Prune d name:
I N STRU CTI ONS — go to vpvw. do h. wajov for More informatfa P
Driver's licenSe, Sooiai $acurity card OT hospital decora-jve birti G rtGfiGala cani m be Lised as proof
Required documentary proof must be submitted with lth-eafrldzivit and Include full name and birth date. Examples of documentary proof include:
Birth/Marriage/Divorce record [Military record (DD..2'14) School transcripts ® Social Security Numident Report
• Certificate of Naturalization Hoap&l/medical record • Pass ort; . Gre-en/Permanent:Resident card 0-55-1y—
Birth Certificates
-I- Only --a parent(s), legal guardian (if the child is under -18), or the named individual (if 18 or older) may change the birth certificate.
2. Tho proof(s) Ynust makel", the asserted'iaot(s), For example, if the affidavit says the name should be Mary Ann Doe, th-6 proof must show the name to be
Mary Ann Doe,
3. Documentary pronti-CILIStbefiVE or more years old crestabli5hed within five years of birth.
Child under IS Adult (18 years or older
If legal guardian(s), include certified Court order provingguardianshipOnly the adult can change his or hee birth certificate
,
lip to age one, last riarrie can be changed once to either parents' name hf the first or middle name is missing, three pieces ofdocumeniary proof are
on certificate (can be any combination of the first, middle or last names)`` required
After age one. a Court order is required lo change fhe. last. name If the first, middle and/or last name is misspelled, or date of birth is incorrect,
Nlo proof is required to change the first or middle nnirrio" Mo pieces of documentary proof are required
To correct parent's information, one documerrtary Proof ' is required, To correct parent's birth date, place of birth, or name, one documentary proof
To correct the sex of the child, one documentary proof from a "nedical is required
provider is required
4TO Change any part of the name of a child, sifqratures ftr,)-m '-,oil17aYent9 iiaied on the caftiAcata are required. if ora parentis deceased, submit a death certificate with request.
This affidavit caner<st be used m add a father to a birth carfficate (use paternly acknowiedgment fora, 00H 422-032)
Death ce�Ufirates
1. Only the infori-na-int the funeral director, Or executors/administrators (H' evidence confirming such position is presented) may change the non-medical
information. Proof is required to snake changes if requestad by q family rnember not lisied as the informant on the certificate (family members are spouse or
regisierod domestic partner, parent, sibling or adult child or stepchild). The informant may change marital status with proof. Marital status requires a certified
copy of a court order if sorneorie other than elle ifforrinaril, is requesting the change.
2. The medical inw�irnation (ca -use of death) mr, a. be changed only by the certifying physician or the coronedmedical axaminer.
-1. Personal facts (inino!- spelling changes In iar`le, date of place of 'hiii-lb or residence) may be changed by he person with one Piece o! documentary proof.
12. To change the dale; or place pf mai-riago or dissoiudoffthe Officiarit ala r1 or clerk of court (dissolution) must comolate and Submit the affidavii.
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CER T I F IED
1402259
Pubfic f[calthim"I
S� otqf�,� K
� A IN
OF YA,H'INGFON
DOH 422-034 October 2016
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