Missouri Division of Health Certificate of Death, Elizabeth Virginia Truman

DEPARTMENT OF SOCIAL SERVICES - MISSOURI DIVISION OF HEALTH STATE FILE NUMBER LIBRAYD (PHYSICIAN, MEDICAL EXAMINER OR CORONER) CERTIFICATE OF DEATH 124 DO NOT WRITE ON THIS STUB REGISTRATION DISTRICT NO. PRIMARY REGISTRATION DISTRICT NO. REGISTRAR'S NO. DECEDENT-NAME FIRST MIDDLE LAST SEX 2 DATE OF DEATH (Mo., Day, Yr.) 4 ELIZABETH 1. VIRGINIA TRUMAN 2. Female 3. October 18,1982 RACE-(e.g., White, Black, American AGE Birthday UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (Mo., Day, Yr.) COUNTY OF DEATH 5A (Type of Units) Indian, etc.) (Specify) (Yrs. White 97 MOS. DAYS HOURS MINS. 4 5a. 5b. 5c. 6. February 13, 1885 Jackson vs 300 7B CITY, TOWN OR LOCATION OF DEATH HOSPITAL OR OTHER INSTITUTION-Nam (If not in either, give street and number) Rev. 1/78 7C 7b. Kansas city 7c. Research Hospital DECEDENT 8 STATE OF BIRTH/ not in U.S.A. CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, SURVIVING SPOUSE (If wife, give maiden name) WAS DECEDENT EVER IN U.S. name country) WIDOWED, DIVORCED (Specify) ARMED FORCES? IF DEATH 10 8. Missouri OCCURRED IN 9. U.S.A. 10. Widowed 11. 12. YES NO INSTITUTION, SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done during most of KIND OF BUSINESS OR INDUSTRY 12 SEE HANDBOOK working life, even if retired) REGARDING COMPLETION OF 14A 13. 495-50-5300 14a. Former First Lady 14b. United States of America RESIDENCE ITEMS RESIDENCE-STATE COUNTY CITY, TOWN OR LOCATION AND ZIP CODE STREET AND NUMBER INSIDE CITY LIMITS 15A (Specify Yes or No) 15a. Missouri 15b. Jackson 15c. Independence 64050 15d. 219 North Delaware 15e. Yes 15B FATHER-NAME FIRST MIDDLE LAST MOTHER-MAIDEN NAME FIRST MIDDLE LAST 15C & E PARENTS 16. David Willock Wallace 17. Madge Gates INFORMANT-NAMI (Type or Print) MAILING ADDRESS STREET OR R.F.D. NO. CITY OR TOWN STATE ZIP 15D 21A 18a. Mary Margaret Daniel 18b 830 Park Avenue, New York City, New York 10021 BURIAL, CREMATION, REMOVAL, OTHER (Specify) DATE CEMETERY OR CREMATORY-NAME LOCATION CITY OR TOWN STATE 24A 19a. Burial October 1982 25 DISPOSITION 19b. Truman Library (Courtyard) 19c. Independence, Missouri FUNERAL SERVICE LICENSEE Or Person Acting As Such NAME OF FACILITY ADDRESS.OF FACILITY 26 (Signature) Chus S. Carson 4173 NUMBER winner Road at Fuller 20a. 26 20b Geo. C. Carson & Sons, Inc. 20c. Independence, Mo. 64052 REGISTRAR DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.) 26 21a. (Signature) 21b. 26 22a. To the best of my death occurreti datt and place and duertothe 23a. On the basis of examination and/or investigation, in my opinion death occurred at the time, cause(s) stated. date and place and due to the cause(s) stated. 26 (Signature and Title) (Signature and Title) 26 DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH CERTIFIER 26 22h Oct.20,1982 22c. 3:50A M 23b. 23c. M 26 NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print) PRONOUNCED DEAD (Mo., Day, Yr.) PRONOUNCED DEAD (Hour) of 27 22d. 23d. ON 23e. AT 4:30 M NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER OR CORONER) / Type or Print MO. LICENSE NO IF HOSP OR INST. Indicate DOA 29A- F 24a. Wallace H.Grahamm.D. Troost Ave. KC.Mo. 21534 OP Rm. Inpatient (Sye CONDITIONS 24b 29G-ST IF ANY 25. Research Hosp WHICH GAVE 26. IMMEDIATE CAUSE [ENTER ONLY ONE CAUSE PER LINE FOR (a) (b), AND (c).] Interval between onset and death 29G-CO RISE TO IMMEDIATE PART CAUSE I (a) Congestive Cardiac Failure 15Min. 29G- CY STATING THE DUETO, OR AS A CONSEQUENCE OF Interval between onset and death UNDERLYING CAUSE LAST (b) Congestive Failure with Edema, Pulmonary 24 Hrs. DUE TO, OR AS A CONSEQUENCEOF: Interval betwegn onset and death TYPE OR PRINT (c) Renal Failure IN CAUSE OF 24Hrs PERMANENT DEATH PART OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not related to cause given in PART I (a) AUTOPSY/Specify Yes WAS CASE REFERRED TO MEDICAL BLACK II Cerebral Vascular Thrombosis No No) EXAMINER OR CORONER INK (Specify No) 27 28. No FOR ACC. SUICIDE, HOM., UNDET. DATE OF INJURY (Mo., Day, Yr.) HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED INSTRUCTIONS OR PENDING INVEST (Specify) SEE 29a. 29b. 29c. M 29d. HANDBOOK INJURY AT WORK (Specify Yes PLACE OF INJURY-At home, farm, street, LOCATION (STREET OR R.F.D. NO., CITY OR TOWN, COUNTY, STATE) IF DECEASED WAS FEMALE or No) factory, office building, etc. (Specify) WAS THERE A PREGNANCY IN LAST 90 DAYS 29e. 29f. 29g. 30. YES NO UNK