•STATE OF MICHIGANLF DEPARTMENT OF PUBLIC HEALTH

CF 16i, CERTIFICATE OF DEATH

1. DECEDENT'S NAME (First, Middle. Last)

HELEN JANE RUBERT4a AGE - Last Birthday 4b. UNDER I YEAR 4c. UNDER I DAY 5. DATE OF BIRTH (Month. Day. Year)

(Years) MONTHS I DAYS HOURS I MINUTES

89 I I J u 1 Y 7, 1902

STATE FILE NUMBER

0423802TYPE/PRINTIN

PERMANENTBLACK INK DATE OF DEATH (Month. Day. Year)2 SEX

Female Jan. 23 19926. COUNTY OF DEATH

Kalamazoo7a. LOCATION OF DEATH (Enter place officially pronounced dead in 7a, 7b, 7c.)

HOSPITAL OR OTHER INSTITUTION - Name (/I not in eitner, give street and number)7b. IF HOSP. OR INST. Inpatient.

Op./Emer. Room, DOA (Specify)7c. CITY, VILLAGE, OR TOWNSHIP OF DEATH

City of Kalamazoo801 Woodward Ave.9b. KIND OF BUSINESS OR INDUSTRY9a. USUAL OCCUPATION (Give kind of work done during most of

working fife. Do not use retired)

Home-maker8 SOCIAL SECURITY NUMBER

Own Home384-46-4758toe. LOCALITY (Check one box and specify) IOd. STREET AND NUMBER

[2'J INSIDE CITY OR VILLAGE OF Ka1 amazooo TWP. OF 8 0 1 WOO d VI a r d A v e .

lOa CURRENT RESIDENCE - lOb COUNTYSTATE

Kalamazoor~i chi g a n10e. ZIP CODE 14 WAS DECEDENT EVER

IN U.S. ARMED FORCES'(Specify Yes or No)

NoI!. BIRTHPLACE (City and

State or Foreign Country)12. MARITAL STATUS - Married, 13 SURVIVING SPOUSE

Never Married. Widowed, (If wife. give name before first married)'Divorced (Specify)Richland TVlp,MI49007 Widowed

17. DECEDENT'S EDUCATION (Specify only highest grade completed)IS. ANCESTRY - Mexican, Puerto Rican, Cuban, Central or SouthAmerican, Chicano. other Hispanic, Afro-American, Arab,English, French. Finnish. etc. (Specify below)

16. RACE - American Indian, Black. White, etc.If Asian, give nationality i.e., Chinese,Filipino, Asian Indian, etc. (Specify below) Elementary ;secondary (0- 12) College (1-4 or 5 + )

2WhiteEn lish19. MOTHER'S NAME (First, Middle. Surname belore tvst memea)

Sarah Electa Crane18. FATHER'S NAME (Fsrst, Middle. Lest)

James Billings Whitlock20b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Village, State, lIP Code)

927 Grand Pre, Kalamazoo, MI 4900620a. INFORMANT'S NAME (Type/Print)

I' Roland J. WhitlockMETHOD OF DISPOSITION - Burial, Cremation,Removal, Donation, Other (specify)

22b. LOCATION - City or Village, State22a. PLACE OF DISPOSITION (Name of Cemetery. Crematory,or other place)

Richland Twp , MichiganPrairie Home Cemetery'I

24 LICENSE NUMBER(of ucensee)

25. NAME ANO ADDRESS OF FACILITY

Joldersma & Klein Funeral Home,917 S. Burdick, Kalamazoo, MI4846

that caused the death. Do!!Q! enter the mode of dying, such as cardiac or respuatorvone cause on each line: I Appronmate

Interval Between

I Onset and Death

I ImmediateIYears

IMMEDIATE CAUSE (Finaldisease or condinon ---.resultmg m death)

InfarctionAcute Myocardiala.

DUE TO (OR AS A CONSEQUENCE OF):

Ischemic Heart Disease(b.

Sequentiauy hst conditions.IF ANY. Ieedmg to Immediatecause. Enter UNDERLYING 1CAUSE (DIsease or Injury c.that uuttated eventsresutnng In death) LAST

--------------------------------.-------.~-,,---~--------PART 11. Other Significant condItIOns contributing to death but not resulting In the underlying cause gi ven in Part I 27a WAS AN AUTOPSY

PERFORMED?(Yes or No)

DUE TO (OR AS A CONSEQUENCE OF):

OUE TO (OR AS A CONSEQUENCE OF):

27b WERE AUTOPSY FINDINGSAVAILABLE PRIOR TOCOMPLETION OF CAUSEOF DEATH' (Yes or No)Fractured Hi D

No28 ACTUAL PLACE OF DEATH (Home. Nursing

Home, Hospital. Ambulance) (Specify)Home29. WAS CASE REFERRED TO MEDICAL

EXAMINER' (Speedy Yes or No)Yesnot to be a medical examiner's case

30a To the best of my knowledge. death occurred at the time. date and place and dueto the cause(s) st,ted

(Signature and Title) " ;;::-;:~~~~~~~;:=t=:_....:.._r;.;::;;..:.;~~::_-----EJ-i;30iiib;-.ID1JArTT'i"E""S<iIr.GNNEi'"1Dn(A:<M;;;o.-.IOh.:::-y.VYr:-'.;,-r3;r0:7c-. ~TI;;M;-;E"'-';O-;:-F-;D:;;E:-;A-:;:T;-;H-------f ~ er 31 b"'wUZ

~~~~~~~~~~~~~~~~~~~~ __~M__~8~ Jan.30d NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Pnnt) ::< r;) 31d

32a. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 26) (Type or Print)

John R. Hunt DO 1820 Shaffer Kalamazoo MI 4900133a ACC. SUICIDE. HOM .. NATURAL 33b DATE OF INJURY (Mo, Day. Yr.)

OR PENDING INVEST. (Specify)NATURAL33c. TIME OF INJURY

M33d

331. PLACE OF INJURY - At home. farm, street, factory,office building. etc. (Speciiv)

33g. LOCATION - Street or RF.D. No. City. Village or Twp State

34b. DATE FILED (Month. Day, Year)

J1150