HomeMy WebLinkAbout03-10-05
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/36
LOCAL FILE NUMBER
,. OECEOENrS NAME (first, MiddIIJ. t..sl)
SaJrah Anne Dic'k
DEPARTMENT OF HEALTH
VERMONT CERTIFICATE OF DEATH
2. SEX
sr"TE FILE NUMBER
3. DATE OF DeATH ,Month. Oily. YtI/JrJ
rYPE OR PAINT
IN BLACK INK
Female
March 29, 2005
1.40ntt1s
Hoo.
Sc.UNDEA 1 DAY
Minul"
6. DATE OF BIRTH (Mo.. D;ly. Yr.)
.. SCX::IAl SECURITY NUMBEA
sa.AGE(Yrs.J
--
204-01-9322
83
May 30, 1921
7. BIRTHPlACE (Cityllnd $1m 01' F~ Co/xItryJ
Carlisle, PA
DOOA
llDtEfI
~Ursil'lSl Homa 0 Residence 0 Olh&r(Sp..tCifyJ
11. VETERAN1(ffso.l1rlvIlwar?)
9. F"elLfTY NAME (lfflOlns~"Jufion. ~'$t'/'ftI6Idrrumber,
Eden Park Nursing Home
12. MARlTAl $TATUS 13. SURVlVlHG SPQlJSE (rtwits,giwJmaiden_)
. Married. CU. NOYtlr m.lnied
or in CU, WIdowed, ~
Never Marrie
Rutland
No
14. DeCEDENT'S USUALOCCUPATlQN (GNelrindf1fMOrlr~ IS. KINO OF8USlNESS I INDUSTRY
duringlOO$lof~.DoImll.lStlrerired.) () E3
~o t,J1
Crystal Cleaning & Po ish:,~:systqJ:
, ,
,_.: r;~\
P l)i:tit~
~ry/SeQ)ndary,o-12)
19, RESIDENCe ST"TE
COIeoeI'....OIS-.)
17, WAS DECEDENT OF HISPANIC ORIGIN? (Specify No 01' Yes
Cuban.Me.ican,Pu_Ricall.etc.)
l!J"
Dyes (SpecHn
Hpes,specify 18. RACE While'-~~~BiicanIrdWi,'ett.-~IyL; t_.~)
-/m - ,"lfi-I
. .::~:~~~ 0 ~~~:J
~.oJh1.te )C)(J ~ Q
21.MAlUNGAODReSS~,CilyOfT-..,Sra/(l,rIfJCoM}~i....-l I I _",. .. '''1'1
)C:. ....: 7~
455 N.Main St. N.Barr~ Mano[".)Ba~r'eYVT
23. MOTHER'S NAME (First Middle, Maiden Slmatnfl! ?: -.J' -' '~'1-~
Ethel King
5
"
OeCEOENT'S EDUCATION
(Sp<<:ifyOllly~grade~J
Vermont
20. CITY, TOWN. OR LOCATION
Barre
22. fATHER'S NAME (FiI'sl.~. lot$/)
Walter Raymond
Dick
CXJ
UI. INFORMAHrS NAME (Type/Prirrr)
Donald Dick
2"b. MAILING AODRESS (StrMI. City, Of T(MTI, Srale, lip Coda)
18 Queen Street, Barre, Vermont
05641
./
IMMEDIATE CAUSE (Final disease (
orcondilion resulting in cleath) a,
CClA<k~ o.X-O;--.0Cl+
OVE TO (OR AS A CONSEOUENCE OF):
('.(),<,","~OJV~ OJ\-kA~
oue TO lOR AS A CONSEOUE~E OFI: J
ell ~0...6~
Approximate Interval
I Between Onset and
Oe.~
110 I'YIIn
I
I' 0 (r~cS-.$
I
I
I
25. PART 1. Enter the diseases. injuries, or complications that caused the death. 00 not enter the mode of dying, such as cardiac or respiralol)'
arrest, shock, or heart failure. Us1 only one cause on each line.
b,
Sequentially list c:onditions, if
any. leading 10 immediate
cause. Entflr UNOERL Y1NQ
CAUSE (Disease Of Injury that
Initiated events resulting in
death) LAST
0,
DUE TO (OR AS A CONSEQUENCE Of):
d.
cue TO (OR AS A CONSEQUENCE OF)-
PART 2. Other significant conditions contributing to death but not resulting in the underlying cause given in Part 1.
~ p, r-" -\-0,\ ~\ l u..AJ..
Va.~ROfDEATH
.~" Okcidenl
;"{3Homlcide OUndel,
27e.INJUflYATWQRI((SpeciIy
V_MHo} No
21b. OATE OF INJURY (Atoorh. Day. Y~ilr) 27t. HOUR
26c.WEREAllTOPSV
FINO/NGS AVAILABLE
PRIOR 10 COMPlETION
OF CAUSE ~TH?
OyllS ANo
27d. HOW 010 INJURY OCCUR? ~r7I~llilllll"eafinju'Yifl PBf11 ",Pa" 2}
268.010TOBACCOUSE
~RIBlJTE TO DEATH?
Yes OPI'lIbabIy
No DUnknown
~b_ WAS AN
AUTOPSy
PERFOR~?
DYeS p9..No
~
27g.LOCATIQN
(S/TU't,orR.F.D.No.
CilyorT(MTI
Stale)
o THE eEST OF MY KNOWlEDGE, ON THE BASIS OF THE CASE HISTORY, EXAMINATION AND/OR
"""OSrn>^T>ON, DEATH OCCURRED AT 'Q ::E:D ".\CE A", DUE TO O.\USE~I A",
MANNER STATED~
28e.(s~J J-u. ~ "'-'-
28b'r:~AN~~:~OFCEE~;;;~
31a.METHOO?F.JllSPOSmON OTemporal)'~
Oaun.r Ii!fCrwmation o RemovalfromS!ala
DOonation o Olher(Sp<<ity)
OSta"phYS.
I:iAttend,p!lys.
OPat!lologfsl
o Mitd.ElCalTlNf
29;1. OATE SIGNEO (rJo.. Day, Yf.j
312-'1105
29t.PROM:llINCfODEAOON:
--.s::.xt,OS-
29tl. HOUR OF DEATH
0;;: ';;5
(Time)
01: ;J S;
/00"'
60 Ma.. ~ ~ 30. NAME Of ATTENDING PHYSIClA.N IF OTHER THAN CERTIFIER (Type or Printl
'lo::U ~
:lIb. PLACE OF TEMPORARY STORAGE (C_ltlry. City or T<lWtI, $/a"'! 31e. PlACE OF FINAL DISPOSITION (ee.n.Mr)' or Cfemaf'Dly. Citr or Toom.
'- s,.~ Green Mountain Crematory
Northfield, Vermont
"., "ME ,"0 ADDRES"Ilb't,'t(W,9R lWlliR'Wh'1'\!~omb Fune r a 1 Home ;;';'~~:;',o' ifr-'Il~-~'
3<Ib. DATE RECEIVED BYMgt~~G~efi (M",!'&(:) 5'"