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! 3a HOUR OF DEATH 3r DATE OF DEATH ?Monih Day
I 2:35 A ,n May 30 ,	1990
4 RACE (Specily White. Black.
American Indian, etc.)
white
5a AGE AT LAST ONLY IF UNDER 1 YEAR ONlY IF UNOER 1 DAY? 6 DATE OF SiRTH iMon'h* Da. ?'ear) |~ BiflTHDAY ;k Mr%C 1 z.~ nAvc -uAime'c.	^	??	r\	i	^
/ y v
'a COUNTY OF DEATH
5b MOS ! 5c. DAYS
II death occurred m an institution, see HANDBOOK, regarding completion of RESIOENCE items
For RESIDENCE items, enter actual location of home rather than mailing address
.so. hours> mins j january 3^	1911 Hancock
7b CITY OR TOWN OF DEATH ; 7c HOSPITAL OR OTHER INSTITUTION-NAME AND NUMBER (If not m \ 76 IF IN HOSP OR INST SPECIFY : 8 STATE OF BIRTH
Bay St. Loui^	23-H j '^outpt rm.or ooAj ^
9 DECEDENT'S EDUCATION Elem/High School Coliege (Specify only higfiesi	1	1	?.a	'	"
grade completed)	1 fO-12' I /.	1	=	..
10. MARRIED. NEVER MARRIED] 11 SURVIVING SPOUSE ill oivej 12 WAS DECEASED EVER IN WIDOWED DIVORCED i	maiden name)	"	US ARMED FORCES"?
(^'MWidowed !
I
?.Yes or No)
no
13 ORIGIN OR DESCENT (Specify Cuban. Afro-Amencan4 Mexican, etc)
Amen can_________________
16a RESIDENCE--STATE 16b COUNTY
><Iississippi Hancock
14. SOCIAL SECURITY NUMBER
426-64-8165
: 15c CITY OR TOWN
Waveland
j 15a. USUAL OCCUPATION	(K.ntf of	,vor-	r>ona	?.5s <'ND OF BUSINESS OR	INDUSTRY
i most of worjjinn life)	!
? Housewife	1	Own Home
j I6d INSIDE CITY	LIMITS ?	16-;	STREET -'iD NUMBER OR RURAL	LOCATION
i (Specify Yes or No>
_______i yes______________1117 Vacation Lane
PARENTS
17. FATHER?NAME	First
Robert
Midde	last
J.	Sbisa
t 18 MOTHER?NAME	F..'st
!	Ellen
M ddlo	Maiden
Reynolds
INFORMANT
19a INFORMANT?NAME (Type or print)
Mrs. Joanne B. Bums
19b MAILING ADDRESS (Street and number or route and nur-s:-?
? or town State, ZIP code)
606 Sunset Drive Bay St. Louis. Ms. 3952C
AND
DISPOSITION
2Ca BURIAL. CREMATION. 20b. CEMETERY. CREMATORY?NAME REMOVAL (Specify)
20c LOCATION (City ana Stale)
; 21a EMBALf.'
nciviw^L	j	: ^	f	yr	//	/?-	^
Burial___________[Gardens of Memory Bay St. Louis jfyis/3^	/. 1 ^
-SlGNAi.JREi-AND nun
21b FUNERAL HOME?NAME AND MISSISSIPPI I D NUMBER
2lc. MAILING ADDRESS (Street and numbe' v 'ode a-:: box mi
Edmond Fahey Funeral Home 2 3E P.O. Box 348 Bay 'St. Louis
lo.vn. Slate 21P code)
Ms. 39520
PRONOUNCEMENT
22a. PERSON WHO PRONOUNCED DEATH?NAME AMD TITLE (Type or pr.nl)
Charles Turner, MD
22b PRONOUNCED DEAD ;Mcnth. Oa.
on May 30, 19 90
an i 22c PRONOUNCED DEAD (Hour)
at 2:35	A..
CERTIFIER
Mississippi Stale Board of Health
Form No 511 Revised M-89
23a CERTIFIER?NAME (Type or print)
Bertin Chevis,
MD
| 23b MAILING ADDRESS ^Street and number or route and cox nurr.:-?*
j 3 07 U lman Ave ^ , Bay_ St_. _Lou
| 24a To tne best of This	and	manner
section	j	SIGNATURE	?
to be com-------------------.
pleted by	;	24b	DATE	SIGNED (Month. Day. Year)
physician	i	r i r r r\ r\
'fNOTa	,	6/6/90
medical--------------------------------
examiner
jf aw knowledge death occurred due to the c aMtatttd-A-_ . /I A	<
PiaJLaa. CMjUA/L-
cause(s)
2*le On the bas.s of examination ann *? occurred due to T9 ca>~?efs) an- ?
i Thts
MD I section ' SIGNATURE ?
----: :o be com------------------- 	------	?
24C STATE LICENSE NUMBER . pieted by ? 24f. TITLE 'med,ca! i
8 318	1	rammer	.
21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER	'	1	2-)g DATE SIGNED (Mcnll-.. Oay. Yea-
C'ty or town. State. ZIP ccdei
is, MS_ 3_9 5_2_0
rvestigation. m my opinion, aeath ?ti-ne* as stated
t
(Type or print)
CAUSE OF DEATH
t;
25. PART I IMMEOIATE CAUSE (Enter one cause onlv) DEATH	/*)
CAUSED ; (a) ke $ P> >(4 Tofu-
Conditions, if any. which gave rise to immediate cause staling the underlying cs^se last
, (J) S-CJ r,J?- (+ W/lOj
OUE TO. OR AS A CONSEQUENCE OF center one cause only)
rJL
DUE TO. OR AS A'CONSEQUENCE OF Er:er one cause oniyV
interval between onset and death
?.<5>./HdJ'j.ful/biT. rcegflrt-L 6y:f:u^i(m<:___________________________________
n*?,r! TO. OR AS A CONSEQUENCE OF Er:er one cause oniyV
LiLtxC)	-	P(lOP)fa*)L6	f)\e.rrt'$7YftiC
SIGNIFICANT fXJNOITICNS-Cono.trai's ranlnOulipg lo cieaih su: 'c: rest mg tr. me underlying cam* :
, Imer/ai between onset and death
Interval between onset and death
26. PART II OTHER
civen in PARly I
tUMtfo
Use il 29a/ ACCIDENT SUICIDE HOMICIDE PEN dealh 1	INVESTIGATION, on UNDETERMINED
NOT I	(Specify)
due to i_________ . .	____________________________________..
natural i 29.3 INJURY AT WORK ' 291 PLACE OF INJUR'-' :i?PC.Iy Home. Fnmv Si.-o--l
IS? Conditions iron
SnlOit L > \0	Cf\y}L	t/Z,__________________
/ni\?
AUTC'5 ;Yfts v
29d DATE OF INJURY 29? -OUR OF INJURY 29c DESCRIBE ; (Month. Day. Year)1
28 WAS CASE REFERRED TO :i:	MEDICAL	EXAMINER0
lYes or Nci
HAT MFANS INJURY OCCURRED
causes
iYes or No)
Factory Office bur.~-?>y. etc.)
29g LOCATION
S^c?r: v?
C"> Or tO'.vr*
State
THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT COPY OF THE CERTIFICATE ON FILE IN THIS OFFICE.