Reg. Dist No.
DO HOT WRITE 'N
MAIlG'N
Il{SfIlll£O 'OR DOH

Primary Reg. DiSl. No.

CERTIFICATE OF DEATH

_

Registrars No.

OATACOO'HG

Ohio Department of Health
VITAL STATISTICS

_

1. Oeceden!"s Name (F"st Middle, LAST)

a.

_

b.

_

c.

_

d.

_

e.

_

Stale File No.

TYPE OR PRINT IN PERMANENT BLACK INK

_

2. Sex

3. Date of Death

MALE
4. Social Security Number

Sa. Age-Last Birthday

I-'Sb::;-:.U",n.:.::d:;:e.:. r.:.D:.:;ne,_y.:.:e;;:a::..r_-+:::;:,==....:..:~,-.,_-l

Months

/Years}

286-68-1094

DB:. 17, 2001
7. B.rthplace
/CIfr, """'Y iIld 5'.. or For.." eo...ryj

(Monrh,II.1y. Yur/

Days

27

(Month. Dar, rur)

11, 1974

HAMILTON, 00.

8. Was Decedem Ever in U.S. Armed Forces? 9a. Place of Death (Check Dn'r One/

hH"o:-:"s":"'pitc:a:7I----------------r;;:;:-:-:-----------------------

0

o

Inpatienl

0

0

ERJDulpatient

0

ReSidence

Other (S~cly/

9d. County of Death

FORr HAMILTON HOSPITAL
10. Mantal Slatus- Marrlf4, ..., Morn...
W.......

Door,..

HAMILTON
12a. Decedenl's Usual Occupation

II. Survivong Spouse (II W4e,

/SpecJr/

12b. Kind of Bus.nessilndustry

(GIve kmd o(work done
dUflng most of working Isf, 00 no' use RetJre-d)

G,ve Malden Name'

If DEATH OCClMUD
IN INSllTUTION. GrvE

IIIESIDEHtE I£fO",(

ADMISS'OH

-+

13a. ReSidence-State

13b. County

OHIO

13c. City, Town, Twp., or Locaoon

HAMILTON

13e. InSide C,ty Um.IS'

13f. ZIP Code

11458 FITCHBURG Ik"'lli

FOREST PARK

16. Decedenfs Educatoon

14. Was Decedent of Hispanic Dngln? 0 Yes
(If Yes, Specify Cuban, Me"c.n. Pueno RIcan. etc.)

0Cl Yes 0

45240

No

17. father's Name

BlACK
ame

(F"st MIddle, Last!

I

""hen

«J1y

G(~d. ComcJtr.4/

OemenlarylSecondary 10-121

conego 11-4 or 5.1

11

(f"st MIddle.

Ma.rlen Surname)

JOHN KNIGHT
19a. Informant's Name
I'

19b. Malhng Address

(TypeIPrlllri

BARBARA HENDRIX
20a. Method of OlSpos'Oon
Bur..1

0 CremallOn

DonatIon

lJ Other

(Sue., and NumurOf Ru"l Route

Number. City or Town, S,.te.lJP Code)

11458 FITCHBURG lANE, CIOCINNATI, OHIO 45240
lOb. Place of DIspOSition (Name o( Cemetery, Crem.wry.
or Olio., PI.ce/

o Removal from Slate

2Oc. Locaoon

HAMILTON, OlUO

ISPIClly,

2Od. Date of Disposition

21a. Name of Embalmer

'I

21b. License Number

(First Middle. Lasrl

6151A

OONAlD H. JORDAN, SR.
22b. License Number (oIlJcensee/

23. ame and Address of facrllty

25. Date fded

(Month, Dar.

Y.a,/

Signalure of Person Issuong Permll
g._---

----

28a. Ceruller

(J

(Chock Dn'r One)

(Include CIty, Stare and llP code)

GREEN, HALL & JORDAN MEM)RIAL CHAPEL
532 soum SEXX)ND STREEI'
HAMILTON, OHIO 45011

5164

h.

City 0' Town. Stall

26b. Dist. No.

27. Date Permit Issued

Certifying Physician
To lhe best of my knowledge. death occurred at the tune. dale. and place. and due to the cau.seh) and manner as suted.

ro Coroner
On Ihe basIS 0' eaaminatlOn and/or InveStlgatlon. in my opinion. death occurred at the tMl'le. dale. and place; and due to the

28b. T,me of Death
~1

9:07
k..

m

(Month, D.y.

December 17, 2001

M

causeh~

and manner as stated.

rearl
DNo

_

28g. Date Signed

(Include City. State .nd lJP cod.1

_

Burkhardt, M.D., Coroner, 315 High St., Suite 650, Hamilton, OH

_

p._--q----

(Month, Day. re.r)

Jan. 25, 2002

35-027548

_

n.
0.

28c. Date Pronounced Dead

(Fmal dlSelJse Of condlCJOn

-+

I Onse' .nd Dea'h

E855.2

Cocaine abuse

fI$uJrmg In death)

45011

ApprOXimate Interval Berween

Part t Enter the diseases, mjuries, or complications that caused the death. Do not enter the mode of dying, such as cardiaC or resprratory arrest.
shock. or hean faliure. List only one cause on each line. Tyoe or orin! in oermanent black ink.
a.
Immediale Cause
b. Due to (0' as a Consequence ofl
Sequenllarty hst cond.uon.s.

u.

_

If any. leadIng to the mmedlate

c. Due to (or as a Consequence of)

cause.
Enter Underlyi"9 C~u.s. Last
(D,jeiJSe Of mJury that Ift/tlated
events resulting

Part II.
SH 'NSrlllJCTIONS
ON R£Y[IIS£ S,oE

1ft

Other s;gn;(;canl cond;l,ons

conlflbulong to death but not resuh,ng rn the underlyIng cause gIven rn Part!'

Other undetermined factors
32 Manner of Death

o Nalural
)C Awdenl
HEA1711
5152 R.v 21'31

d. Due to (or as a Consequence ot)

death)

o SVlclde

o Pendong
IrwesllgalJOn

U Could NOI be
Oetermtned

0' CilUSli! of Death'

~Yes 0
33d Describe How Inlury Occurred

33b. Time ot Inlury

33a. Date of InJUry

pprox

(Month, Day. rear/

12-17-2001

31a. Was an Autopsy 31b. We,e Autopsy F.. dlngs
Performed?
Available Prior (0 Compleoon

1: 50 AM

M

33e. Place of Inlury - AIHocn•.f.. m.S..... f"IOrf.Ot'c.B~.•"

street

0

)Q}Yes

0

0

drug abuse
33t. Locallon ISue.' and Number or Rural Rou,e Number. Cily or Town. S'ale'

East Avenue at Sycamore Street,
~T.:>mi't-,...,n_

()1-l