State of
Florida
Dept. of Health & Rehab. Svcs.
Vital Statistics
Decedent #5102 |
CERTIFICATE OF DEATH FLORIDA |
State File
No. ____
Local File No. __ |
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1. Decedent Name:
WESLEY G. DEIBLE
2. Sex: Male
3. Date of Death: Aug. 24, 1979 |
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4. RACE: White
5a. AGE: 44
6. DATE OF BIRTH: Apr. 30, 1935
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7a. COUNTY OF DEATH: Manatee
7b. CITY, TOWN, or LOCATION OF DEATH:
Bradenton |
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7c. HOSPITAL OR OTHER INSTITUTION:
Blake Memorial |
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7d. IF HOSP. OR INST.: Emer. Room |
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8. STATE OF BIRTH: Ohio
9 CITIZEN OF WHAT COUNTRY: USA |
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10. MARRIED, NEVER MARRIED, WIDOWED,
DIVORCED: Divorced |
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11. SURVIVING SPOUSE: (BLANK) |
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12. SOCIAL SECURITY NO.: 270-30-0664
13a. USUAL OCCUPATION: Line forman |
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13b. KIND OF BUSINESS OR INDUSTRY: Electric
Appl. Mfg. |
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14a. RESIDENCE: Florida
14b. COUNTY: Manatee
14c. CITY, TOWN or LOCATION: Bradenton |
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14d. STREET & NUMBER: 5408 17TH St.
W. 14e. INSIDE CITY LIMITS:
No. |
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15. FATHER-NAME: Gordon Deible
16. MOTHER-MAIDEN NAME: Olive Spurling |
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17a. INFORMANT: Ruth Waters
17b. MAILING ADDRESS: 5408 17th St. W.,
Bradenton, FL 33507 |
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DISPOSITION: |
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18a. BURIAL CREMATION, REMOVAL, OTHER:
Removal |
18b. CEMETERY OF CREMATION: Rest Haven
Cemetery
18c. LOCATION: Montgomery, Ohio |
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19a. FUNERAL DIRECTOR: Joseph R.
Shannon |
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19b. FUNERAL HOME: Shannon Funeral Home,
1015 15th St., W. Bradnenton, FL.
33505 |
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CERTIFIER: |
20a. To the best of my knowledge,
death occurred at the time, date and place
and due to the causes stated.
(Signature and Title) Robert L. Batey,
M.D. |
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20b. DATE SIGNED: Aug. 24, 1979
20c. HOUR OF DEATH: 5:23 p.m. |
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21. BLANK |
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22. NAME AND ADDRESS OF CERTIFIER:
Robert L. Batey, M. D., 5223 Manatee Ave.
W., Bradenton, FL |
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23a. REGISTRAR: (Signature)
Nancy E. Gus____ ___ |
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23b. DATE RECEIVED: Aug. 27, 1979 |
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CONDITIONS IF ANY WHICH GAVE RISE TO
IMMEDIATE CAUSE - STATING THE UNDERLYING
CAUSE LAST: |
24. IMMEDIATE CAUSE: a. Ventricular
Fibrillation - Duration 1 hr.
( b). DUE TO OR AS A CONSEQUENCE OF (b)
Acute Myocardial infarction - Duration 1
hour
(c) DUE TO OR AS A CONSEQUENCE OF:
Arteriosclerotic Cardiovascular Disease -
Duration Unknown |
I hereby certify the above to be a true and
correct copy of the record on file in the
Office of the Local Registrar of Vital
Statistics at the Manatee County Health
Department.
Date: August 27, 1979
By: Nancy E. Gros__ski, Deputy
Registrar of Vital Statistics (SEAL) |
