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VERIFY PRESENCE OF ODH WATERMARK HOLD TO LIGHT TO VI W
<br /> Ohio Department of Health
<br /> Peg.Dist.No. 47 VITAL STATISTICS
<br /> Primary Meg.Dst.No. 4700 CERTIFICATE OF DEATH
<br /> Type or print in permanent blue or blade Ink State File No.
<br /> Registrars NO. 2008000539
<br /> 1.DocedenraLegal Name(Include AKA's it any)(Flrst Middle,LAST,suffix) - 2.Sex 3.Date of Death(No/Day/Year)
<br /> SUSAN MARIE PETRILLA Female May 24,2008
<br /> 4.Social Security Number 5a.Age Sb.Under t Year 5c.Under 1 day 8.Date 01 BkUt(MoIOay/Yea) 7.eirtbpiace(Clty and State or Foreign Country)
<br /> e) Months I Days I flours I Minutes
<br /> 295-46-4186 5$ May 26,1949 BEREA,OHIO
<br /> Ba.Residence Slate ' 80.County 80.Cm or Town
<br /> fs OHIO LORAIN WELLINGTON
<br /> ® SC.Street and Number Be.Apt.No. 8f.Zlpcode 8g.Inside City Um
<br /> 46329 Merriam Rd. }� 44090 Yes
<br /> ®_ 9No r in US Anted Forces? 1MaorleSl Status at Time of Dealh 11.,r nno all (gytit�4ve name prior to first marriage)
<br /> ice 12.Decodonra Education 13.Decadent of Hispanic Origin 14.FDi leceedent's Race
<br /> ® HIGH SCHOOL GRADUATE OR No White
<br /> ® GED
<br /> MI N
<br /> ®0 15.Fathers Name 16.Mothers name(prior to first marriage)
<br /> ®� GEORGE STUMPF • JOANNE MILLER
<br /> 17a.Informants Name 176.Relationship to Decedent 17c.Mailing Address (Sven and Number,City,Stab,Zip G
<br /> BERNARD J PETRILLA Husband 46329 Merriam Rd.
<br /> 184.Place of Death
<br /> Decedent's Home WELLINGTON,OHIO 44090
<br /> 1 ab.Facility Name(Knot Institution,give street B number) 180.City or Town,Slate and Zip Code 18d.County at Death
<br /> 46329 Merriam Rd. WELLINGTON,OH 44090 LORAIN
<br /> N
<br /> er 19 lure of Fun�Asl Service Licensee or Other Agent 20.License Number(of licensee) 21.Name and Complete Address of Funeral Facility
<br /> N k /Y/y�4 008624 BODNAR-MAHONEY FUNERAL
<br /> - o 2 a.Mothod of Disposition U 226.Date of Disposition
<br /> HOME
<br /> Cremation 074Y ZF too?
<br /> p 22c.Placa of Disposition(Nave of Cemetery,Crematory,or other place) 22d, Lion(City/Town sew State) 3929 LORAIN AVE
<br /> 0
<br /> GREAT LAKES CREMATORY CL' -ELAND,OH CLEVELAND,OH 44113
<br /> 23.Reglst,ar s Signature 24.Dale Filed
<br /> cc /10,4.x.1 if . 4 , , • -_ ',."May 29, 2008
<br /> m 251 limo of Person issuing Burial Permit • 250. strict No. 25c.Date Burial Permit issued
<br /> B RWALD,ANGELA 1 MAY it, zoo(
<br /> w
<br /> tea.Cartdlor 0 Certifying Physician
<br /> (Check only one) To Ms bee el my ymowiedge.death marred at me ems.dab,and gam add y'stb Me cause(sl and marine-med.
<br /> nCoroner .----
<br /> lb On de bola of seeminaton mar inrmasuarkin my opinion,aath0owmed,jibe time,due.and game:aid due to Me esuselq end man=sbtad.
<br /> 280.Time of Death 26c.Data Pronounced Dead(k".oiDay/Year) "---/ 28d.Was case referred to coroner?
<br /> cc � /, 'U i?tAy`�-c-1,2oe No
<br /> U 26e.Si slure and Title of Cer "r 261.License number 285.Data Signed•f)4 _(,C y - (142 M D 35.030809 luny a.1 0400 g
<br /> 27.Name(Last,First.MbNe)and Address of Person who Cdnpleted Cause of DDilath,
<br /> ZAWORSKI,DANIEL CARLTON,5255-N-ABBE RD ELYRIA,OH_44035
<br /> 28.Pen L Snap the disease,illume,or oompaatere stet caused Me deals.On rue wen tfw mods of dying.arir r It ca�ac(ir respiratory arrest,shod,or heart lsnore.List Approximate Interval
<br /> may pro.r.a an odd,are.Tyvo monist in pewnerunt Owe or dace OM. Between Onset and Dee
<br /> immediate Cause a --._
<br /> Mimi tessera or condom,
<br /> •
<br /> resumngindeath) C/'NcA1,- ... ✓)F `i K c4 2 i S Y C✓-e s
<br /> SequenUaily list 0.Due to(or as Consequencd,ot)
<br /> conditions,II any.
<br /> leading to Unmedlate
<br /> = ceUIIe' c.Duo to(or as Conseguence,ol)
<br /> FL
<br /> a EnterUnderiying Cause
<br /> O (Disease or injury that
<br /> Lc') Initiated events resulting d.Due to(or as Consequensxi o0
<br /> wi n a death)
<br /> rn •
<br /> 0
<br /> a Port iI.other significant aondaene contributing to firth but net resulting In the underlying cause given In Inn I. 294 Was An Autopsy 29b.Were Autopsy Findings
<br /> Performed? Available Prior To Completion C
<br /> "
<br /> Dyes NO Cause u of Death?
<br /> Oyes ❑No QNeS Applies
<br /> 30.Did Tobacco Use Contribute to Death? 31. 1Lprude,Pregnancy Status 32.Manner of Death
<br /> (I�Nef regeee1withis put year jil Natural ❑Homicide
<br /> ❑yes ❑Unknown 1H-III Pregnant at time of death
<br /> Not pregnant,but pregnant within 42 days of death ❑Accident 0 Pending Investigation
<br /> Ea No ❑Probably Not pregnant,but pregnant 43 days to 1 year before death ❑Suicide ❑Could not be tletermin
<br /> Unknown II prednent within the past veer
<br /> 33a.Data of Injury(MoiDaylYeer) 33b.Time of Inlay 33c.Plan of Injury(e.g.,Decedent's home,construction site,restaurant,wooded area) 33d.Injury at Work?
<br /> Dyes 0 N
<br /> 33e.Location of injury(Street and Number or Rural Route Number,City or Town,Stale)
<br /> 331.Describe How Injury Occurred: 33g.B Transportation Injury,Specify:
<br /> Gomm/operator ❑Pedestrian ❑PassengI
<br /> Other:
<br /> Fr, g it d
<br /> ami∎rams-ea,rasa=a1el:=ronIeaemnnel:∎:metauNtaa>•ilre4:11Mt aa=rnariENNI111
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