S TAT E O F F L O R I D A

OFFICE

of

V I TA L

S TAT I S T I C S

C E RT I F I C AT I O N O F D E AT H
STATE FILE NUMBER: 2013150651

DATE ISSUED: March 30, 2015

DECEDENT

STATE FILE DATE: November 8, 2013

I N F O R M AT I O N

N A M E : S TA N L E Y S T E V E N S O N

SEX: MALE SSN: 333-28-3343 AGE: 077 YEARS

DATE OF DEATH: October 30, 2013

DATE OF BIRTH: July 19, 1936

BIRTHPLACE: CHICAGO, ILLINOIS, UNITED STATES

P L A C E O F D E AT H : I N PAT I E N T

FACILITY NAME OR STREET ADDRESS: VETERANS ADMINISTRATION HOSPITAL PALM BEACH

LOCATION OF DEATH: WEST PALM BEACH, PALM BEACH COUNTY

SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION

M A R I TA L S TAT U S : D I V O R C E D

SPOUSE (IF FEMALE. MAIDEN NAME): NONE

RESIDENCE: 13435 CROSSPOINTE DRIVE, PALM BEACH GARDENS, FLORIDA 33418, UNITED STATES COUNTY: PALM BEACH
OCCUPATION, INDUSTRY: MILITARY CAREER, UNITED STATES AIR FORCE
RACE:

White

Black

American

Of African American Asian

Indian

Guamian

or

Alaskan

or

Indian

Chinese

NativeTribe:

Chamorro

Filipino

Vietnamese

Samoan

Other

Native

Other

Hawaiian

Japanese

Korean

Asian:

P a c i fi c

Isl:

Other

Unknown

HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC/HAITIAN ORIGIN

E D U C AT I O N :

PA R E N T S

A S S O C I AT E

AND

DEGREE

INFORMANT

EVER

IN

U.S.

ARMED

FORCES?

YES

I N F O R M AT I O N

FAT H E R : F E L I X S T E V E N S O N
M O T H E R : E L I Z A B E T H TAT U M

INFORMANT: SELENA STEVENSON

R E L A T I O N S H I P T O D E C E D E N T: D A U G H T E R

INFORMANTS ADDRESS: 13435 CROSSPOINTE DRIVE, PALM BEACH GARDENS, FLORIDA 33418, UNITED STATES
PLACE

OF

DISPOSITION

AND

FUNERAL

FACILITY

I N F O R M AT I O N

P L A C E O F D I S P O S I T I O N : S O U T H F L O R I D A N AT I O N A L C E M E T E R Y

LAKE WORTH, FLORIDA

METHOD OF DISPOSITION: BURIAL

FUNERAL DIRECTOR/LICENSE NUMBER: TERRY PLATTS, F042754

F U N E R A L FA C I L I T Y: V E T E R A N S F U N E R A L C A R E I N C F 0 4 0 0 0 2

15381 ROOSEVELT BLVD, CLEARWATER, FLORIDA 33760

CERTIFIER

I N F O R M AT I O N

TYPE OF CERTIFIER: CERTIFYING PHYSICIAN

MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE

TIME OF DEATH (24 hr): 1605

C E R T I F I E R ' S N A M E : M I C H A E L A S I LV E R M A N
CERTIFIER'S LICENSE NUMBER: ME26590

NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT APPLICABLE

CAUSE

OF

D E AT H

AND

INJURY

I N F O R M AT I O N

P R O B A B L E M A N N E R O F D E AT H : N AT U R A L

CAUSE OF DEATH - PART I - and Approximate Interval: Onset to Death:

Ws.

a PNEUMONIA

b DYSPHAGIA

C DIABETES MELLITUS

PART 11 - Other significant conditions contributing to death but not resulting in the underlying cause given in PART I:
A R T E R I O S C L E R O T I C H E A R T D I S E A S E / PA R A LY S I S O F S C I AT I C N E R V E

AUTOPSY PERFORMED? UNKNOWN

D AT E O F S U R G E R Y:

A U T O P S Y F I N D I N G S AVA I L A B L E T O C O M P L E T E C A U S E O F D E AT H ? U N K N O W N
D I D T O B A C C O U S E C O N T R I B U T E T O D E AT H ? U N K N O W N

R E A S O N F O R S U R G E RY:

IF FEMALE. NOT APPLICABLE

TIME OF INJURY (24 hr)

D AT E O F I N J U R Y: N O T A P P L I C A B L E

I N J U R Y AT W O R K ?

L O C AT I O N O F I N J U R Y :
DESCRIBE HOW INJURY OCCURRED:

P L A C E O F I N J U R Y:

IF TRANSPORTATION INJURY. Status of Decedent:

Type of Vehicle:

REQ: 2015807547

.State Registrar
THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE.

WARNING;

THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH WATERMARKS OF THE GREAT
SEAL OF THE STATE OF FLORIDA. DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATER
MARKS. THE DOCUMENT FACE CONTAINS A MULTICOLORED BACKGROUND, GOLD EMBOSSED SEAL. AND
THERMOCHROMIC FL. THE BACK CONTAINS SPECIAL LINES WITH TEXT THIS DOCUMENT WILL NOT PRODUCE
A C O L O R C O P Y.

DH FORM 1947 (11/11)

CERTIFICATION OF VITAL RECORD:

ff

H E A L T