STATE OF FLORIDA DEPARTMENT OF Reubin O'D Askew, Governor Health & Rehabilitative Services District Eight Sarasota County Health Dept. P. 0. Box 2658 Sarasota, Florida 33578 State of Florida CERTIFICATE OF DEATH Department of Health and Rehabilitative Services STATE FILE NO. VITAL STATISTICS FLORIDA REGISTRAR'S NO. DECEASED-NAME FIRST MIDDLE LAST SEX DATE OF DEATH MONTH, DAY, YEAR ) TYPE OR PRINT IN 1. C. PERMANENT WILSON CHAMBERLIN 2. Male 3. December 28, 1978 BLACK INK RACE WHITE, NEGRO, AMERICAN INDIAN, AGE-LAST UNDER YEAR UNDER I DAY DATE OF BIRTH (MONTH, DAY, COUNTY OF DEATH ETC. SPECIFY BIRTHDAY (YEARS) MOS DAYS HOURS MIN. YEAR 4. White 5a. 75 5b. 5c. 6Aug. 31, 1903 7a. Sarasota CITY, TOWN, OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION - NAME (IF NOT IN EITHER, GIVE STREET AND NUMBER SPECIFY YES OR NO 7b. Venice 7c. Yes DECEASED 7d. Venice Hospital STATE OF BIRTH (If NOT IN U.S.A NAME CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED. SURVIVING SPOUSE (IF WIFE, GIVE MAIDEN NAME ) COUNTRY) WIDOWED DIVORCED SPECIFY) USUAL RESIDENCE 8. Pennsylvania 9. U.S.A. 10. Widowed 11 None WHERE DECEASED LIVED. IF DEATH SOCIAL SECURITY NUMBER USUAL OCCUPATION (GIVE KIND OF WORK DONE DURING MOST OF KIND OF BUSINESS OR INDUSTRY OCCURRED IN WORKING LIFE, EVEN IF RETIRED INSTITUTION, GIVE RESIDENCE BEFORE 12. 074-10-5000 13a. Broker 13b. Real Estate ADMISSION RESIDENCE-STATE COUNTY CITY, TOWN, OR LOCATION INSIDE CITY LIMITS STREET AND NUMBER (SPECIFY YES OR NO ) 14a. Florida 14b. Sarasota 14c. Venice 14d. Yes 14e664 Flamingo Dr. Apt. 20 FATHER-NAME FIRST MIDDLE LAST MOTHER- MAIDEN NAME FIRST MIDDLE LAST PARENTS 15. Charles Sumner Chamberlin 16. Maude Ethel Brown INFORMANT-NAME MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) 17a. Louise H. Marr 17b. 238 W. Tampa Ave., Apt. 202, Venice, FL 33595 PART 1. APPROXIMATE INTERVAL DEATH WAS CAUSED BY: [ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)] BETWEEN ONSET AND DEATH 18. IMMEDIATE CAUSE Heart Disease ? (a) DUE 10, OR AS CONSEQUENCE OF: CONDITIONS, IF ANY, WHICH GAVE RISE TO (b) IMMEDIATE CAUSE (a), STATING THE UNDER- DUE TO, OR AS A CONSEQUENCE OF: LYING CAUSE LAST CAUSE (c) PART II. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (a) AUTOPSY IF YES WERE FINDINGS CON ( YES OR NO) SIDERED IN DETERMINING CAUSE OF DEATH 19a. Yes 19b. Yes (Probably) ACCIDENT, SUICIDE OR DATE OF INJURY I MONTH, DAY, YEAR) HOUR HOW INJURY OCCURRED (ENTER NATURE OF INJURY IN PART I OR PART 11, ITEM 18) HOMICIDE: OR UNDETERMINED (Specify) 20a. 20b. 20c. M. 20d. INJURY AT WORK PLACE OF INJURY AT HOME, FARM, STREET, FACTORY, LOCATION (STREET OR R.F.D. NO. CITY OR TOWN, STATE SPECIFY YES OR NO OFFICE BLDG., ETC. (SPECIFY) 20e. 20f. 20g. CERTIFICATION- MONTH DAY YEAR MONTH DAY YEAR AND LAST SAW HIM HER ALIVE ON I DID QTR NOT DEW THE DEATH OCCURRED AT THE PLACE, ON THE PHYSICIAN: MONTH DAY YEAR BODY AFTER DEATH TO (HOUR) DATE, AND, TO THE BEST I ATTENDED THE 21a. DECEASED FROM 2-14-78 21b. 12-28-78 21c. 12-27-78 21d. Did NOT 21e.4.43A. M. TO THE CAUSE(S) STATED OF MY KNOWLEDGE ou CERTIFICATION-MEDICAL EXAMINER OR CORONER: ON THE BASIS OF THE HOUR OF DEATH THE DECEDENT WAS PRONOUNCED DEAD EXAMINATION OF THE BODY AND/OR THE INVESTIGATION, IN MY OPINION, MONTH DAY YEAR HOUR CERTIFIER DEATH OCCURRED ON THE DATE AND DUE TO THE CAUSE(S) STATED 22a. M. 22b. M CERTIFIER- (TYPE OR PRINT) SIGNATURE When a. faxes DEGREE OR THE 50. DATE SIGNED (MONTH, DAY, YEAR 23a. JohN L. Suscia M.D. 23b. 23c. 12-29-78 MAILING ADDRESS-CERTIFIER STREET OR R.F.D. NO. CITY OR TOWN STATE ZIP HRS Form 512, 23d. 1990 South TAMIAMI Trail Venice Florida 33595 May 1977, R(e BURIAL, CREMATION, REMOVAL CEMETERY OR CREMATORY- NAME LOCATION CITY OR TOWN STATE places OPCVS SPECIFY Form VS#612) 24a. Cremation 24b. Ft. Myers Crematory 24c. Ft. Myers Florida BURIAL DATE MONTH, DAY YEAR ) FUNERAL HOME NAME AND ADDRESS STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP Dec. 30, 1978 24d. 25a. Farley Funeral Home, P.A., 265 Nokomis Ave., Venice, FL 33595 FUNERA 25b DIRECTOR SIGNATURE REGISTRAR SIGNATURE 26a. Bibbee Jus DATE RECEIVED BY LOCAL REGISTRAR Rebecca A 26b. Dec 29, 1978 A CERTIFIED COPY MUST CARRY THE EMBOSSED SEAL OF THE REGISTRAR OF VITAL STATISTICS. THIS IS A CERTIFIED COPY OF A DEATH RECORD ON FILE IN THE OFFICE OF THE LOCAL REGISTRAR OF VITAL STATISTICS, SARASOTA, FLORIDA. DATE December29,1978 DEPDTY REGISTRAR