stone death certificate

\ DEPARTMENT OF STATE HEALTH SERVICES VITAL STATISTICS UNIT TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS JAN 23 2015 STATE OF TEXAS CERTIFICATE OF DEATH STATE FILE NUMBER 142-15-007851 1 LE E OF ŒC l 's. U , 1 I F ' . . I l ) I I 2. DATE of DêTH· OR P R EMED ,_, JANUARY 19 2015 JAMES HENRY STONE 3. 1 - DATE OFlH (·) I �· AGt y 1F1woA 1YR B. BIRTHPL¬E (City & S+ F > MOUNTAIN HOME AR MALE APRIL 22 1982 l (Y "I 32 I I ,. 7.� 18 � STATATnOFTH O M a 9. RVIVING E'S E (II w, e p l ngul � 0 D W- D - Na D A , 1. RESICE STREET RE �. I I. STATE TEXAS 1 1.ZIPE n>1 1 1. CI OR TO CONROE 1 1. INSIDE CITY LIMITS? µY 0No 12. MOTHER'S R TO FIRST RGE MONTGOMERY 11. FATHER'S WALLACE FRANKLIN STONE JOAN MCGINNIS 13. E OF DêTH (CH Y E) IF DêTH CURRí IN A AL 11F DêTH CURRED HER A . O !- 0 �• 0 ꝃ A I O F-v ONuRlnn tm>I to O (vl 14 . DêTH , ,s IIIV, t ,uTYUtT CTI , ,e. F¬ITYN(ll l,SUNI) MONTGOMERY , CONROE n301 17 INFO & RE' 1 IP TO DECD 1 18. RE OF IN C• P C) JOHN ALLEN HOSKINS V - SI GNIFICANT OTHER CONROE TX n301 19 MET OF DISIT 4. � - -u,n�, UH -n- 21. 0 &l � Ctemal O ¬TING H '� - ! _______ _ D " o--- CORA LEE LEAN ,BY ELECTRONIC SIGNATURE - O au, 1•-��·1 11ccc2 ! l 6 . � E � : o 1 F �o�,�, S IT =1 = = ry . a = Y , =, 1 = -7 , T , "1c • ,1 T o , , - - , , 1 ----- L! s MCNU BRK CREMATORY CONROE TX i 24. OF E F¬ILITY { 9. M RESS OF F F¬ITY ( a N, Cy, Sta , Z J MCNU FUNERAL HOME 1ɘ PORTER ROAD CONROE, TX 77301 ; :. CERTIFIER (� 1) O C To i, * s) . l Eaunimd P . � � � @ e. p@. • '(S) I , ! ;.�TURE CERTlER <. DATE CERTIFIí (t , Ó. M¾R ,>. TI OF DEATH(ual num) WAYNE'L MACK BY ELECTRONIC SIGNATURE JANUARY 22 2015 I 12:14 AM � _ 31. ID E. R ÎRTIAER (SlI , y, t , . TnLE OF CERTIFIER - . I i � WAYNE L MACK 19380 HWY 105 W. STE 507, MONTGOMERY, TX n356 JP ! ". PART 1 . ENTER T Of NTS - , lRI, OR T - TT RECTLY CAUSED THE Dê TH TER U TI ES REST, REITORY REST, OR VENTfUCR ABT wtTT G T oale oal l to th I Y. # T TE. R LY CꜶ . � ITE E (Fal i !• x « - > a. � H � A � N � G � l � N � G !---------------- ----------- i i ) ( U a ): ti� i � ,� 5 i : �� -------- - � - , - « - u - , - -- -- - 1: ---------------- tna L r Iha YING CꜶ \ �� ---------------------------- dl T e ( as a� ): ' i i PAJ If 2. , I UIn� I F� S RII ﬃ PE A T T RETG IN THE UNDERLYING $ W AN ꜶTSY PERRMED? µYus 0No l f E GIVEN IN PT L � %. WERE AUTOPSY FIINGS AVAILE TO ETE THE OF DêTH? Yes ONo &. MNER OF DêTH 37 TCCO l , "'' '. IF FE . D N TO DêTH? ( IF I MIAu.m IRY, ECIFY D D Y O ﬆ r O Pr al tme @ 0No ON .. , D O O . "3 1 ' D e r O Pr o- D l1,1 g : O M 4. DATE OF IAY() l '" T OF IRY r 4. �RY AT RK? l" OF IY (e.g. O e, lr1 ᐰ. r�. a1N) JANUARY 19, 2015 12:14 AM D Y • No I BEDRꝃM � 4. U,KAT tNl N, Cy,e, ) NTY OF INRY MONTGOMERY CONROE TX n301 41 DERIBE RY CURRED HANGED SELF 4. REGIST A NO. > 01-0139 FAA NI ER u;,1:uu 1 42b. DATE RIVED DY REGIST JANUARY 6. 2015 1 • . REG tst REGISTRAR - MONTGOMERY COUN CLERK, ELECTRONICALLY FILED AMENDMENT TO CERTIFICATE OF DEATH VITAL STATISTICS Texas Depaent of Ste Health Seis DêTH NO #7851 D . REGISS FUU DêTH CERTIFTE I ÚTE OF DêTH JAMES HENRY STONE 01/1912015 PLACE OF DêTH· CNTY t MONTGOMERY CONROE CC ITEM OR ITEM NO fﬂY CERTIFIÊTE CORRECT INFT 1 . JAMES HENRY STONE JAMES HENRY STONE-HOSKINS 8. NEVER RIED RRIED 9. -- - ;, OHN ALLEN STONE-HOSKINS, V 17. JOHN ALLEN HOSKINS V - SIGNIFICANT OTHER . UOHN ALLEN STONE-HOSKINS, V - HUSBAND I CT s OF T OR�''��TRY BY Wi lSSUED O SIGNED DATE lSSUEO AFFID OF INFORNT, JOHN ALLEN 0715 ) BOBBY LEE NOVAKOSKY, NOTARY 08/06/2015 STONE-HOSKI NS, V PUBLIC, STATE OF TES COPY OF COURT ORDER, CAUSE NO. 0832015 UNITED STATES DISTRICT COURT 08/0512015 -13-CA2LG FOR THE WESTERN DISTRICT OF TAS, SAN ANTONIO DIVISION ÎRW IHeREY nnFY T I HA THE U LISTED O TT T TT IS TRUE D CCT � e�.�� DATE FID 2015 STATE REGISR VS-173 REV. 9/^ Texas Depat of State Health Seis - Vital Stabst ,\ I I

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Stone Death Certificate

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DEPARTMENT OF STATE HEALTH SERVICES VITAL STATISTICS UNIT

TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS JAN 23 2015 STATE OF TEXAS CERTIFICATE OF DEATH STATE FILE NUMBER 142-15-0078511 LEGAL NAME OF OECEASEO llndudo N

MOUNTAIN HOME AR MALE APRIL 22 1982 l(Y

"""I 32 I Mo I oa,. 7.ALSECURITYNUMBER 18 ALSTATUSATnMEOFOEATH O Manl8d 9. SURVIVING --......... E'S NAME (II wile, QMI name priDI IO ltrSC maniagul

Ii ... 0

D Wclo- D - l'i,l Na .......... D Unknown !'Ob.APT NU, 1oa. RESIDENCE STREET ADDRESS

. I

IQe. STATE

TEXAS 1

10l.ZIPCOOE

n301

110c. CITY OR TOWN

CONROE

110g. INSIDE CITY LIMITS?

181Yos 0No 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE

MONTGOMERY 11. FATHER'S NAME

WALLACE FRANKLIN STONE JOAN MCGINNIS 13. PlACE OF DEATH (CHECK ONLY ONE)

IF DEATH OCCURRED IN A HOSPrr AL 11F DEATH OCCURRED SOMEWHERE OTHER TJ-W,l A HOSPITAL. O Iopa!- 0 ER.Ou"'"" 0 OOA I O ........ F-v O NuRlnn tm>I l'i,l Decadlol'> tm>o O Otho, (Splcilvl 14.COUNTY OF DEATH

,,s l,;IIYIIVWN, Dt" tlF ...... ,..-..,.;uTYUt.UT.::M:PRECIHCTNOI ,

,e. FACILITYNAME(llnol insllution,QCWSUNIDddrMSS)

MONTGOMERY , CONROE n301 17 INFORMANT"S NAME & RELA' 1 JUMM1IP TO DECEASED

118. MAILlNG ADDRESS OF IN C P Code)

JOHN ALLEN HOSKINS V - SIGNIFICANT OTHER CONROE TX n301 19 METHOD OF DISPOSITION 20. SE Of -..... -..-- u,n,..,... UH -.an.n.n-. 21. 0 &,nal Ctemalmn O Ootultioo ACTING AS SUCH

' - Sec101 _______ _ D Entom""""" o--- CORA LEE MCLEAN ,BY ELECTRONIC SIGNATURE -O au,., 1-1 11 ccc2 ! l..22li'.'a:PLACE:o.sl1Fo,,,,..,.,,S""IT'"ION=1"'11ome="'o1"'com= ... ::cry:c.-::aoma=::::IOIY::::-:,...,=,-::;p1oa1;::!:!,1f-!-2=;_-.-.,.23,-;.......,.""',.T10N,""""1c"';::.,1T;;,:o:::..,::-,-:::-::,-..:,sw;:;,,1,---------lL01

s. MCNUTT BROCK CREMATORY CONROE TX 5paca i 24. NAME OF FUNERAL FACILITY { 25. COMPLETE ADDRESS OF FUNERAL FACILITY (StnNM and Number, Clly, Stnta, Zip CodeJ .5 MCNUTT FUNERAL HOME 1600 PORTER ROAD CONROE, TX 77301 ; 26. CERTIFIER ( only one)

O Co,dying pnpidan-To ,-NS o1 mr i..nowi.dgu, d8illtl DIXUINd "' 10.,. c:.wse(s) and rNtM8I staled. (8l Modal Eaunimd.Jusllcu of ine Puce. On lhu basil OI ard'ot In my opnion, tlCCWNd at Iha time.dale Mid plMat. Id dull ta hi CM&Sl.'(S) ..00 INll'V"1f liuued,

! 27.TURE OF CERTlflER 28. DATE CERTIFIED (rnnHSd-yyyyt ,211. LA-EN::u: NUMBER ,30. TIME OF DEATH(Aclual Of prnumed)

jj WAYNE'L MACK BY ELECTRONIC SIGNATURE JANUARY 22 2015 I 12:14 AM _ 31. PAINTED NAME. ADDRESS OF CERTIAER (SlrHI and Numblll, Clily,Stale.Zip Cadet

,32. TnLE OF CERTIFIER

-::: '-. I i WAYNE L MACK 19380 HWY 105 W. STE 507, MONTGOMERY, TX n356 JP .5 ! 33. PART 1 . ENTER THE CHAIN Of EVENTS - DISEASES, lNJURIES, OR COMPUCATKlNS -THAT OIRECTL Y CAUSED THE DEA TH QQ.lQ! ENTER ;j U TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTfUCULAR ABRIU.ATION wtTHOUT SHOWING THE

Approaimale intorval Onsal to death

I .X ETIOLOGY. 00 NOT AIIBREVIATE. ENTER ONLY ONE CAUSE ON EACH. IMMEDtATE CAUSE (Final i ! x ....... condolion-> a.HANGlNG!.----------------------------:_ i i resuling In dNlh) 0"8 IO (DI U a consaquenc:e af): ti -=i , 5 .Iii .e:

":t,':!' --------Oua-

-

,--

u-

,-

con.equ--

onco--

ol-1:

---------------lisled on tna L Enlar Iha UNOERL YING CAUSE

\ :::::a ----------=---,--------c:------------------in daa!hl LAST Oue lO (or as a con of):

'

i i PAJ If 2. o;;i-., laO' I UI n SfGNIFIC CQN91T19NS CONJRIBUJINO ffi PEA TH BUT NOT RESULTING IN THE UNDERLYING 34 WAS AN AUTOPSY PERFORMED? 181Yus 0No l f CAUSE GIVEN IN PART L

'; 35. WERE AUTOPSY FINDINGS AVAILABl..E TO COMPLETE THE CAUSE OF DEATH?

0,Yes ONo 36. MANNER OF DEATH 37 Dill TOBACCO USE l.,Uf'I , "'PV' '- 38. IF FEMALE.

D Nat