8/14/2019 1496 KY Taylor, Fannie Death

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1727328FORM VS NO. 1-A(Rev. 5/02)

COMMONWEALTH OF KENTUCKY 1CABINET FOR HEALTH SERVICES

1"REGISTRAR OF VITAL STATISTICS

CERTIFICATE OF DEATH

qiilHMUST / 1 - DECEDENT'S NAME {First, Middle, Last)TYPED FANNIE __ TAYLOR4. SOCIAL SECURITY NO.

405 | 42 | 81245a. AGE LastBirthday (Years)

8 3I. WAS DECEDENT EVER INU.S. ARMED FORCES?

ra NO

5b. UNDER T YEAR{Months) | {Days) 5c. UNDER 1 DAY(Hours) J {Minutest

2. SEXFemale

3. DATE OF DEATH {Month. Day, Year)June 1 7 , 2 0 0 4

6. DATE OF BIRTH {Month. Day. Year)

Mav 0 8 , 1 9 2 19a. PLACE OF DEATH {Check only one)

7. BIRTHPLACE {City/State orForeign Country)A l b a n y , K Y ^ / / ^

9b. FACILITY NAME (If not institution, give street and numb er}r) 2-,J e w i s h H o s p i t a l

l u o r n AL , OTHERj ^ ] Inpatient / D ER/Outpatient DOA | Q Nursing Home Residence O Other {Specify)

10. MARITAL STATUSMarried, Never MamedWidowed, Divorced {Specify)Marrj ed13a. RESIDENCE-StateK e n t u c k y13e. INSIDE CITYLIMITS?

O Ves

9c. CITY. TOWN. OR LOCATION CL o u i s v i l l e11. SURVIVING SPOUSE{If wife, give maiden name)

E d w a rd T a y l o rC l i n t o n 0*113f. ZIP CODE

4 2 6 0 217. FATHER'S NAME {First. Middle, Last)

B u r r H o l s a p p l e

12a. DECEDENTS USUAL OCCUPATION{Give kind of work done during most ofworking life. Do Not use retired)

9d. COUNTY OF DEATHJ e f f e r s o n

Homemaker 7 / 413c. CITY, TOWN, OR LOCATIONA l b a n y

14. WAS DECEDENT OF HISPANIC ORIGIN?(Specify No or Ye s - If yes, specify Cuban,Mexican, Puerto Rican, etc.)H No D Yes 0

19a. INFORMANT'S NAMEE d w a rd T a y l o r

20a. METHOD OF DISPOSITIONL i Burial L J Cremation

R 5 h12b. KIND OF BUSINESS/INDUSTRY

U k Lsekeepi

H o u s e k e e p i n g13d. STREET AND NUMBERRt . # 2 Box 1238

15. RACE - American Indian,Black, White, etc. [Specify)W h i t e I

16. DECEDENTS EDUCATION(Specify only highest grade completed)Bern/Secondary (0-12)

18. MOTHER'S NAME (Frst. Middle, Maiden Surname)I d a N i c h o l a s

College (1-4 or 5+)o19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, Stale, Zip Code)

R t . # 2 B o x 1 2 3 8 , A l b a n y , KY 4 2 6 0 2L J Removal from State

I I Donation Other (Specify)21. SIGN >f URE OF FUNERAL SIacting as such) ICE LICENSEE

20b. PLACE OF DISPOSITION (Name of cemetery,crema tory, or other place)

P e o l i a Cemetery

23a. To the best of my knowledge, death occurred at the time, date, place and due to the causes stated

S igna ture and T i tle la e f f ik & s a s a t 1%4-fA

22. NAME AND ADDRESS OF FACILITY1X 5 C r o s s S t . ,

20c. LOCATION (City, Town, or State)

A l b a n y , KYCAMPBELL FUNERAL HOMEA l b a n y , K Y 4 2 6 0 2

(MUST USE BLACK INK)24. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 28)

23b. DATE SIGNED(Month, Day, Year)

25. TIME OF DEATH 26. DATE PRONOUNCED DEAD (Month, Day, Year) 27. WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER? Yes Q No

' 28. PART 1 Enter the diseases, injuries, or complications that caused death. Do not enter the mode of dying, such as cardiac orrespiratory arrest, shock or heart failure. L ist only one cause on each line. Approximate interval betweenonset and death.

CA U S E O FD E A T H

IMMEDIATE CAUSE (Finaidisease or conditionresulting in death)

Sequentially list conditions, ifany, leading to immediatecause. Enter UNDERLYINGCAUSE (Disease or njury thatinitiated events resulting indeath) LAST

DUE TO (OR AS A CONSEQUENCE OF]:

DUE TO {OR AS A C ONSEQUENC E QJPJTy * j d iDUE TO (OR AS A CONSEQUENCE OF);

PART It. Other significant conditions contributed lo death but not resulting in the underlyingcause given in Part I.v 28d. Did the deceased have Diabetes?j jbJ 4*4-**g %JssMJ.

29 MANNER OF DEATH JS NOQ NaturalQ Accident0 Suicide1 1 Homicide

Q PendingInvestigation Could not bedetermined

30a. DATE OF INJURY(Month, Day. Year)

28a. If female, was there apregnancy in the past12 months? Yes 0 ^ o

28b. Was an autopsyperformed? Yes EBCNI

28c. Were autopsy findingsavailable prior to completionof cause of death? Yes No28e. Was Diabetes an immediate, underlying, or contributing causeof or condition leading to death? OY