2tegt0trar cf llital ^tattHttca

T H E F A C E O F THIS D O C U M E N T HAS A C O L O R E D BACKGROUND - N O T A WHITE BACKGROUND

1727328
FORM VS NO. 1-A
COMMONWEALTH OF KENTUCKY
CABINET FOR HEALTH SERVICES 1
1
"
qiilH
(Rev. 5/02)
REGISTRAR OF VITAL STATISTICS

CERTIFICATE OF DEATH
MUST / 1 - DECEDENT'S NAME {First, Middle, Last) 2. SEX 3. DATE OF DEATH {Month. Day, Year)

TYPED FANNIE __ TAYLOR Female June 17, 2004

4. SOCIAL SECURITY NO. 5a. AGE Last 6. DATE OF BIRTH {Month. Day. Year) 7. BIRTHPLACE {City/State or
Birthday (Years) 5b. UNDER T YEAR 5c. UNDER 1 DAY
{Months) | {Days) (Hours) J {Minutest Foreign Country)

405 | 42 | 8124 83 Mav 0 8 , 1921 Albany, KY^//^

I. WAS DECEDENT EVER IN 9a. PLACE OF DEATH {Check only one)
U.S. ARMED FORCES?
luorn AL , OTHER
ra NO j ^ ] Inpatient / D ER/Outpatient • DOA | Q Nursing Home • Residence O Other {Specify)
9b. FACILITY NAME (If not institution, give street and number} 9c. CITY. TOWN. OR LOCATION C 9d. COUNTY OF DEATH

r) 2-, Louisville Jefferson R 5h

10.
Jewish H o s p i t a l11. {If
MARITAL STATUS
Married, Never Mamed
SURVIVING SPOUSE
wife, give maiden name)
12a. DECEDENTS USUAL OCCUPATION
{Give kind of work done during most of
12b. KIND OF BUSINESS/INDUSTRY
Widowed, Divorced {Specify) working life. Do Not use retired)

Marrj ed
13a. RESIDENCE-State
Edward Taylor
13c. CITY, TOWN, OR LOCATION
Homemaker 7/4 Housekeeping
13d. STREET AND NUMBER
Uk L
sekeepi
Kentucky
13e. INSIDE CITY 13f. ZIP CODE
Clinton 0*1 Albany
14. WAS DECEDENT OF HISPANIC ORIGIN? 15. RACE - American Indian,
R t . # 2 Box 1238
16. DECEDENTS EDUCATION
LIMITS? (Specify No or Yes - If yes, specify Cuban, Black, White, etc. [Specify) (Specify only highest grade completed)
Mexican, Puerto Rican, etc.) Bern/Secondary (0-12) College (1-4 or 5+)
O Ves 42602
17. FATHER'S NAME {First. Middle, Last)
H No D Yes
0 White I
18. MOTHER'S NAME (Frst. Middle, Maiden Surname)
o±
Burr Holsapple Ida Nicholas
19a. INFORMANT'S NAME 19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, Stale, Zip Code)

Edward Taylor R t . # 2 Box 1238, Albany, KY 42602

20a. METHOD OF DISPOSITION 20b. PLACE OF DISPOSITION (Name of cemetery, 20c. LOCATION (City, Town, or State)
LJ Removal from State crematory, or other place)
L i Burial LJ Cremation

I I Donation • Other (Specify)

Peoli a Cemetery Albany, KY
21. SIGN>f URE OF FUNERAL SI ICE LICENSEE 22. NAME AND ADDRESS OF FACILITY
acting as such) CAMPBELL FUNERAL HOME
1X5 C r o s s S t . , Albany, KY 42602
23a. To the best of my knowledge, death occurred at the time, date, place and due to the causes stated 23b. DATE SIGNED
(Month, Day, Year)

Signature and Title laeffik&sasa t 1%4-fA

(MUST USE BLACK INK)
24. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 28)

25. TIME OF DEATH 26. DATE PRONOUNCED DEAD (Month, Day, Year) 27. WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER?
• Yes Q No

' 28. PART 1. Enter the diseases, injuries, or complications that caused death. Do not enter the mode of dying, such as cardiac or Approximate interval between
respiratory arrest, shock or heart failure. List only one cause on each line. onset and death.
IMMEDIATE CAUSE (Finai
disease or condition
resulting in death) DUE TO (OR AS A CONSEQUENCE OF]:

Sequentially list conditions, if DUE TO {OR AS A CONSEQUENCE QJPJTy * £ j d i

any, leading to immediate
cause. Enter UNDERLYING
CAUSE (Disease or injury that
initiated events resulting in DUE TO (OR AS A CONSEQUENCE OF);
CAUSE OF death) LAST
DEATH
PART It. Other significant conditions contributed lo death but not resulting in the underlying 28a. If female, was there a 28b. Was an autopsy 28c. Were autopsy findings
cause given in Part I. pregnancy in the past performed? available prior to completion
12 months? of cause of death?
v »•• jjbJ 4*4-**g %Js£sMJ.
28d. Did the deceased have Diabetes?
• Yes 0 ^ o • Yes EBCNI
28e. Was Diabetes an immediate, underlying, or contributing cause
• Yes • No

JS • NO of or condition leading to death?

30b. TIME OF INJURY
OY<* J3NO
30d. DESCRIBE HOW INJURY OCCURRED
29 MANNER OF DEATH 30a. DATE OF INJURY 30c. INJURY AT WORK?
(Month, Day. Year)
Q Natural Q Pending
Q Accident
Investigation • Yes • No
0 Suicide • Could not be 30e. PLACE OF INJURY - At tiome, farm, street, 30f. LOCATION (Streer and Number or Rural Route Number. City or Town)
determined factory, office building, etc. {Specify)
1 1 Homicide

31. REGISTRAR'S SIGNATURE 32 DATE FILED

mrs 7m
THE B A C K O F T H I S D O C U M E N T C O N T A I N S A N A R T I F I C I A L W A T E R M A R K - H O L D AT A N A N G L E T O VIEW

I, Gary L. Kupchinsky, State Registrar of Vital Statistics, hereby certify this to be a true and correct copy of the certificate of birth, death, marriage or divorce of the
person therein named, and that the original certificate is registered under the file number shown. In testimony.thereof I have hereunto subscribed jny name and
caused the official seal of the Office of Vital Statistics to be affixed at Frankfort, Kentucky this / O Eg 7TL2

2 0
^ &±JjJ&A
Gary L. Kupchinsky, State Re