STATE OF FLORIDA J m Ws. OFFICE of VITAL STATISTICS ^ C E R T I F I C A T I O N O F D E A T H STATE FILE NUMBER: 2013150651 DECEDENT INFORMATION N A M E : S T A N L E Y S T E V E N S O N DATE ISSUED: March 30, 2015 STATE FILE DATE: November 8, 2013 S E X : M A L E S S N : 3 3 3 - 2 8 - 3 3 4 3 A G E : 0 7 7 Y E A R S BIRTHPLACE: CHICAGO, ILLINOIS, UNITED STATES DATE OF DEATH: October 30, 2013 DATE OF BIRTH: July 19, 1936 PLACE OF DEATH: INPATIENT 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 T A L S T A T 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 X Black O f A f r i c a n A m e r i c a n A s i a n Indian Chinese Filipino Native Hawaiian Japanese Korean American Indian or Alaskan Native—Tribe: Vietnamese Other Asian: Guamian or Chamorro Samoan Other Pacific Isl: Other Unknown HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC/HAITIAN ORIGIN EDUCATION: ASSOCIATE DEGREE EVER IN U.S. ARMED FORCES? YES PARENTS AND INFORMANT INFORMATION F A T 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 T A T U M INFORMANT: SELENA STEVENSON RELATIONSHIP TO DECEDENT: DAUGHTER INFORMANTS ADDRESS: 13435 CROSSPOINTE DRIVE, PALM BEACH GARDENS, FLORIDA 33418, UNITED STATES PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION PLACE OF DISPOSITION: SOUTH FLORIDA NATIONAL CEMETERY LAKE WORTH, FLORIDA METHOD OF DISPOSITION: BURIAL FUNERAL DIRECTOR/LICENSE NUMBER: TERRY PLATTS, F042754 FUNERAL FACILITY: VETERANS FUNERAL CARE INC F040002 15381 ROOSEVELT BLVD, CLEARWATER, FLORIDA 33760 MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE CERTIFIER INFORMATION TYPE OF CERTIFIER: CERTIFYING PHYSICIAN TIME OF DEATH (24 hr): 1605 CERTIFIER'S NAME: MICHAEL A SILVERMAN CERTIFIER'S LICENSE NUMBER: ME26590 NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT APPLICABLE CAUSE OF DEATH AND INJURY INFORMATION PROBABLE MANNER OF DEATH: NATURAL CAUSE OF DEATH - PART I - and Approximate Interval: Onset to Death: a P N E U M O N I A b DYSPHAGIA C DIABETES MELLITUS PART 11 - Other significant conditions contributing to death but not resulting in the underlying cause given in PART I: ARTERIOSCLEROTIC HEART DISEASE/ PARALYSIS OF SCIATIC NERVE AUTOPSY PERFORMED? UNKNOWN DATE OF SURGERY: REASON FOR SURGERY: IF FEMALE. NOT APPLICABLE DATE OF INJURY: NOT APPLICABLE LOCATION OF INJURY: DESCRIBE HOW INJURY OCCURRED: PLACE OF INJURY: IF TRANSPORTATION INJURY. Status of Decedent: AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? UNKNOWN DID TOBACCO USE CONTRIBUTE TO DEATH? UNKNOWN TIME OF INJURY (24 hr) I N J U R Y A T W O R K ? Type of Vehicle: .State Registrar REQ: 2015807547 WARNING; THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE. 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: S i HEALT ff