Sand Springs Economic Development Authority - SSEDA

FIREFIGHTERS PENSION BOARD NOTICE OF SPECIAL MEETING AND AGENDA July24,2013-8:15a.m. Sand Springs Municipal Building 100 East Broadway, Administration Sand Springs, Oklahoma 74063 1. Call to Order Roll Call 3. Minutes The minutes of the January 31, 2014, Special Firefighters Pension Board meeting for the Committee's review and/or approval. ACTION: 4. Application of Death Benefit and Surviving Spouse for Pension Ms. Karen L. Broomhall, spouse of former Firefighter Rodney G. Broomhall, has submitted an Application for Death Benefit and Surviving Spouse for Pension. The Pension Board will consider approval of said application for death benefit and surviving spouse for pension. ACTION: 5. Adjournment This agenda was posted at 3:15 p.m., on July 19, 2013, on thebtrttetin board located in the lobby of the Sand Springs Municipal Building, 100 East Broadway^^and Springs, Oklahoma, 74Q63, by Janice L. Almy, City Clerk. Janice L. Almy, City Clerk  MINUTES Sand Springs Firefighters Pension Board Sand Springs Municipal Building 100 East Broadway - Administration Sand Springs, Oklahoma 74063 January 31, 2013 - 8:30 a.m. The Firefighters Pension Board met in special session on January 31, 2013 in Administration offices of the Sand Springs Municipal Building, pursuant to the special meeting notice and agenda filed with the City Clerk's office and posted at 8:25 a.m., on January 29, 2013 on the bulletin board located in the first floor lobby of the Sand Springs Municipal Building, 100 I^^Broadway, Sand Springs, Oklahoma, 74063. 1. Call to Order The meeting was called to order at 8:3; 2. Roll Call It was noted for the records Jeremy , Stephen Brewer and Dan Call were in attendance. Ricky Pate and Janig 3. Minutes A motion was m seconded by Stephen Brewer that the Firefighters Pension Board meeting, as prese Ayes^fi/ade, Brewe Nay: None 4. Applicittn of for irement Pension Ricky E. Pate SBHPned an Application for Retirement Pension and Participation under the Back Drop Provision for review and/or approval by the Board. Following review of the application and discussion, a motion was made by Dan Call and seconded by Jeremy Wade that the requested approval of Application for Retirement Pension and Participation under the Back Drop Provision for Ricky e. Pate, as presented, be approved. Ayes: Wade, Brewer, Call Nay: None 5, Adjournment The meeting adjourned at the noted time of 8:35 a.m.  Oklahoma Firefighters Pension and Retirement System 4545 N. Lincoln Blvd. Suite 265 Oklahoma City, OK 73105-3407 1-800-525-7461 • (405) 522-4600 • Fax (405) 522-4643 www.okfirepen.state.ok.us APPLICATION FOR DEATH BENEFIT Title 11, Section 49-113.2 reads in part: Upon the death of an active or retired member, the System shall pay to the surviving spouse of the member if the surviving spouse has been married to the firefighter for thirty (30) continuous months preceding the member's death provided a surviving spouse of a member who died while in, or as a consequence of, the performance of the member's duty for a participating municipality shall not be subject to the marriage limitation for survivor benefits, or if there is no surviving spouse or no surviving spouse meeting the requirements of this section, the System shall pay to the designated recipient or recipients of the member, or if there is no designated recipient or if the designated recipient predeceases the member, to the estate of the member, the sum of Five Thousand Dollars ($5,000). The Death Benefit is subject to state and federal taxation. A surviving spouse may elect to directly rollover the distribution to an Individual Retirement Account (IRA). Only a surviving spouse can make this election. Please indicate your choice below. (CHECK ONE) C Direct Rollover- Please submit a copy of your IRA Agreement. (WIDOW ONLY) f-r/Twenty percent (20%) will be withheld for federal income tax as mandatory under Code section 3405(c) if distribution is paid u® directly to the applicant. (WIDOW ONLY) []] If applicant is other than spouse, a Form 19a is required for tax withholding information, (i.e. If benefit is going to a funeral home) v_> _, do hereby make application for the death benefit of J\o was a member of the Oklahoma Firefighters Pension and Retirement System and served on the a Q JC., _Fire Department. The benefit shall be in the amount of $5,000.00 as provided pursuant to Title 11, O.S., Section 49-1 13.2 and 49-100.1(16). Deceased Member's SSN „, . ._ _ Applicant's Signature (Widow, Recipient, OR Funeral Home) Applicant's SSN _ . . _'_-_.: -~_ " ^— _ i } 1 \ (If applicant is Guardian of minor child, use child's SSN) /V , LvYVd) Mailing Address Tax ID for Estate or Trust. (If applicable) City State Zip Dated this day of _ State of OKI fl-A Phone )ss. County of^/g City Code. K Q fe. n Z~-./") rfoo mho, I I , first being duly sworn on oath deposed and says that he/she, is the Applicant above named, that he/she has read the within and foregoing application, knows the contents thereof, and that the statems^e-e«M:f^i7etr-th^TElrr^reTfDfe and correct. ~~ Subscribed and sworn to before rne this J(& day of My Commission Expires /,-A ~___' Q "~/ &? Notary Public If applicant is the Guardian of minor child(ren) or Conservator of mentally or handicapped child(ren), please list names and birthdates. Name Birth Date Name Birth Date Form 19 Rev. 05/07 (over) If applicant is the Surviving Spouse of the deceased member, the following items must be submitted with application: Copy of Marriage Certificate Copy of Death Certificate of Member If applicant is Designated Recipient of the deceased member, the following items must be submitted with application: Copy of Death Certificate Separate Tax Form for Designated Recipient (other than spouse) 'Notarized Death Benefit Recipient Form must be on file in pension office. If applicant is Administrator of the Estate of the deceased member, the following items must be submitted with application: Copy of Court Order appointing Executor of Estate Copy of Death Certificate of Member " Death Benefit does not apply to members who have elected a vested benefit. ** Form 13 (Application for Entrance Into the Pension System) must be on file in the State Pension Office in order for an individual to qualify for this benefit. Form 19 Rev. 05/07  Oklahoma Firefighters Pension and Retirement System 4545 N. Lincoln Blvd., Suite 265 Oklahoma City, Oklahoma 73105-3407 1-300-525-7461 • (405) 522-4600 • Fax (405) 522-4643 www.okfirepen.state.ok.us Application for Surviving Spouse for Pension Before the Board of Trustees of the Oklahoma Firefighters Pension and Retirement System, _Oit.fVa.JS>rir- tf\o_ Fire Department, r -j City of ^XyvA Sp^v-v-'-. V_ County of ""T7 ', \ Oklahoma. ~ ' In re: Application for Pension of ry-y--'U'>fO'-j_ (,-jy VSvvVVyiV:: V\ pursuant to Oklahoma Statutes, Title II, Section 49-101 and 49-106, Supp. 1981. ' (member's name) COMES NOW 1 -^ W Na. sA> use of U deceased, and hereby (as shown on social security card) *- makes application to the Board of Trustees of the Oklahoma Firefighters Pension and Retirement System fora pension and respectfully submits the following: 1 .That applicant is the spouse of said deceased firefighter, was married to him/her at the time of his/her death for more than thirty (30} continuous months prior thereto. If in line of duty, this does not apply. 2. That at the time of firefighters death said deceased was a parent of the following named unmarried children under the age of eighteen (18) years, or twenty two (22) years of age if the child is enrolled full-time and regularly attending a public or private school or any institution of higher learning, or physically or mentally disabled children, to wit: NAME OF CHILD: BIRTH DATE: NAME OF CHILD: BIRTH DATE: OFPT. NAME FOR OFFICE USE ONLY fODF FIREFIGHTERS' i SOCIAL SECURTIY NUMBER RETIREMENT CODE PREP BY: PAYU-C 1 ASS SPOUSE'S SOC ^TATI K REV BY: SPOUSE'S BIRT HDATE _ ~ ~ - -*— ._ : - PENSION AMOUNT APVBY: MARRIAGE DAI DEDUCTIONS { fany): FEDERAL TAX OTHFR INS DFTAILDUES STATE TAX CRFDITUNinN OTHER A RETIREES DUES MISC. OTHER B MUNICIPAL INS MIITUAI.AID OTHFR f ENTER DIRECT DEPOSIT INFORMATION BELOW (OR ATTACH A VOIDED CHECKTO FORM} BANK NAME BANKADDRESS ACCOUNTNUMBER BANK PHONE NUMBER CITY STATE ZIP CODE ROUTING NUMBER 3. That applicant is the widow of said deceased, who was a fireman duly appointed and enrolled In the Fire Department of ... --,. . :: , Oklahoma at the time of his/her death, and that said deceased fireman served a total of years, months, and days, as a member of a duly constituted Fire Department of the State of Oklahoma. That said service began on the day of , , and ended on the day of , . 4a. That said deceased, on the __ day of , _ , died from causes not arising in the line of duty or in the course of his employment as a member of said Fire Department. 4b. That said deceased, on the day o f , ., died by reason of an injury or sickness sustained by hirn/her while in consequence of the performance of his/her duty as a member of said Fire Department. (over) Form 3 Rev. 12/08  5a. If Death in Line of Duty, applicant requests that a monthly pension of S. _be granted, (If regarding a paid firefighter who has served twenty years, applicant is entitled to a monthly pension of one-half (1/2) of the average monthly salary of the firefighter's highest salaried thirty consecutive months of the last sixty months of service. If firefighter served less than twenty years, benefit is based on the average monthly salary of the last thirty months of service.) If regarding a volunteer firefighter, applicant is entitled to the full volunteer pension being paid to service retirees.) Said sum to be paid from the Oklahoma Firefighters Pension and Retirement System in accordance with the laws of the State of Oklahoma in such cases made and provided. 5b. If Death was Not In Line of Duty, applicant requests that a monthly pension of <•- ^ .be granted. (If regarding a paid firefighter, benefit is based on one-half of the firefighter's last sixty months average salary, (!f regarding a volunteer nrengnter, applicant shall be entitled to 1/20 of the normal volunteer service pension for each year of service.) Said sum to be paid from the Oklahoma Firefighters Pension and Retirement System in accordance with the Jaws of the State of Oklahoma in such cases made and provided. Was firefighter receiving a pension at time of death? If YES, what was the amount of pension? S Was firefighter's death a result of injury or sickness sustained by him/her while in or in consequence of performance of his/her duty? [ No J, Was firefighter's death a result of injury or sickness from causes notarising in line of duty? {TTlYeS r L -j ^,O Did firefighter serve as much as twenty (20) years in one or more fire departments in the state of Oklahoma? F^jYes Had firefighter been approved fora vested benefit? If so, what date was benefit to begin? Dared this 1L day of Applicant's Signature (as shown on social security card) Mailing Address City State ZIP Code State of Oklahoma )SS. County of 'Hi Phone ren A J; (fomna // , first being duly sworn on oath deposed and says that he/she is the Applicant above named that he/she has read the within and foregoing application, knows the contents thereof, and that the statements contained therein are true and correct. Subscribed and sworn to befi y My commission expires PLEASE ENCLOSE: 1. MINUTES OF YOUR LOCAL PENSION BOARD MEETING (if applicable) (Minutes from town counsel cannot be accepted). 2. COPY OF DEATH CERTIFICATE 3. COPY OF MARRIAGE LICENSE 4. FEDERAL AND STATE WITHHOLDING TAX FORM (FORM 6)(if not attached, taxes will automatically be withheld due to federal regulations) 5. AFFIDAVIT VERIFYING LAWFUL RESIDENCE IN THE UNITED STATES (FORM 24) 6. A VOIDED CHECK FOR DIRECT DEPOSIT Return to: OKLAHOMA FIREFIGHTERS PENSION AND RETIREMENT SYSTEM 4545 N. Lincoln Blvd., Suite 265 Oklahoma City.OK 73105-3407 Form 3 Rev. 12/08  Oklahoma Firefighters Pension and Retirement System 4545 N. Lincoln Blvd., Suite 265 Oklahoma City, Oklahoma 73105-3407 l-SOO-525-7461 • (405) 522-4600 - Fax (405) 522-4643 www.okfirepen. state, ok.us Affidavit Verifying Lawful Presence in the United States Applicant's Name pCVMr\ ,1 Applicant's SSN Fire Department Q ' 1C-. ~~ ' TJ All Natural persons fourteen (14) years of age or older and present in the United States, applying for retirement benefits from the Oklahoma Firefighters' Pension and Retirement System are required, by the Oklahoma Indigent Health Care Act (56 O.S. Supp. 2007 § 71), to provide verification of lawful presence in the United States by executing an Affidavit below before a notary public or other officer authorized to notarize affidavits under State law. Please check one of the applicable boxes below. L. , of lawful age, being first duly sworn, upon oath states, under (Applicant's Name) penalty of perjury, as follows: (Check one) [£fTam a United State Citizen. I am a qualified alien under the Federal Immigration and Nationality Act and I am lawfully present *—' in the United States. Applicant's Signature State of SS. County of I * It Subscribed and sworn to-before me this day of / My commission expires Notary Pdblic (Seal) Form 24 Rev. 11/07  MAHRIAGE RECORD NO. 73 . OKUAHOM* APPLICATION FOR MARRIAGE LICENSE STATE OF OKLAHOMA, COUNTY OF CREEK, ss. IN DISTRICT COURT We, thc/imdersigncd, hereby,j?pply for the issuanc<M>f a Marriage License and certify as-to our ages anc' places oj/residcnce as follows: / &f // ' F) PS? ^/ sf / S Name. i#^t-l2^-'l~^/^^<~&~^i^ -, A Age. P-fi ^ ^° QJ' t^^^—'f^/ ^^2^^'S*---st~^' ~ .State of. -, Age. .^2. I^UUJILHJ r.'/^J O 1^4.. QI. . y ^ ,f f 1 i^l,, State of. ,11 -f "-—^ - _i _ ^,_ -{_. • ; and for the purpose of procuring same, we do solemnly t_JL-*tl*C *' ' - *- L_ -^ . ' . ^^ i . r "—cf.J -—' ..- — ~« .—-r- •' -|— *f UliLJ ±\JL yi*i_, f^L»i^v^*J^- V-i- ^ i u v- «-*- *** {3 ^n swear that the names, ages and places of residence as set out above are true and correct, as evidenced by docHmients described in particular as follows; (First Pnrty) ((^J^J^ , ofi*&T• ^/- <£ /- ^"<^ ; (Second Party) MT antf^iat we are not disqualified^or incapable Amder tjie law of entering into the marria^e--r-elajion, nor .are to eacl^t5ier within the degree prohibited by law. .Applicant Applicant Subscribed andMworn to before'me thia_ .Judge DOROTHY CRAWFORD. Court Clerk. Court Clerk. L • -I _ • Note—In event one or both of the parties to bo married are under afre, such applicntion'shall have been on f^le i.n'the Court 'Cleric's office for n period of not less tlmn seventy-two hours, prior t o t h e issuance of the license. • ' . ' . ' ' : . . ENDORSEMENT: By thla endorsement I hereby v:rlfy. and truly certify, that the Application for ait Id License was accompanied by proper credentials under, the circumstances Indicated by the word "filed" opposite one o r more o f the applicable provlsio.is of Stntuto indicated below. ' * ' - . " • ^-_~^HTO) Phyalolan's and laboratory technician's otatomenta wqufred by stntute, relotlvo to the examination and heaJth oi.' either or both of the parties. .(2) An order of tho District Coui!t, with memoranda of rcaaonB for the order dlsperisJnK with ntfltutory requlrtmenla relative to 'the cxanilnntlon and health of either or both of (ho parties. . ; • . " • • _ • • - ' . " .(3) An order of (lie. Dlatrlct CoUit with accorapanyina memornnda of renaone for the order, extending .tha 30 day period following the .examination" to 90 days or Iflsj, touether with pai>«ra comiilyinir with the reniilrernenU of number (I) nbove. - ' - , ( i ) Affidavits of consent to marriafffl of an underage person by parent or guardian. In lieu of personal ePPearnceo as provided by SUtuto 43 O.S. 1071 } 3, . .(6) Affidavit of consent to mftnlatra of sn underage per»6n by parent or guardian, realdlnir fn another county' of th'is State or outslda the State'and ackn.ow3edeed ni provided by Statute 43 O.S. 1971 S S. • ' . . ''- ,—(6) Affidavit of thre« person* au'.horUIr;? marrlfl.ea o( aee per«on when parent* are or otherwise Incapable of g^vins consent. Statute 43 O.S." 1971'j 3.' Witness my hand and official aeal this 4— day of '-^ (SEAL) . DOROTHY CRAWFORD, Court Clerk. -Deputy Consent Affidavit—In Person (1) '{ I, the undersigned, state that I am the, _of. jianied in the jl : ; nbove application as being of the a^a of_ -yenrs. and fn the nroscnca of  L c r n u i i I,-, I, the'undersigned, state that I am the_ .of- .named in the above application as being of the age. of: _years, and in the presence of the issuing official, I do hereby consent to. .marriage to. _ . Signed this day of . .,19. In the presence of -(Sip). DOROTHY CRAWFORD, Court Clerk, By • • - . , . . . .: OR Judge - MARRIAGE LICENSE .THIS^LICENSE VALID ONLY IN STATE OF OKLAHOMA STATE OF OKLAHOMA, COUNTY OF. CREEK, ss. . . " • - ' I N DISTRICT COURT TO ANY -PERSON AUTHORIZED "TO JERFORM OR "SOLEMNIZE THE: MARRIAGE CEREAIONY - GREETING: /) ' ' s**} ' ' ' ' ' •" f/ f} hereby author izedf 'un/n delivery, of ;tW^marriage Heense within ten days from date of ita issue to/you', .to join in/riarriagG Mr. County of years; and by the command of the statute you shall make:c]ue return of this license to my office witliin five days : succeeding the performance of the marriage herein authorized. . - -Issued under my hand'and official seal, and recorded in my Marriage Record, before.delivery at'Sapclpa, Oklahoma, this ,-^—-X- /" \ ' ' . T- • ' :• •• '. ,, day 'of. OROTHY CRAWFORD, Court Clerk. By. D o pu ty ^ CERTIFICATE OF M A R R I A G E STATE OF OKLAHOMA, COUNTY .OF. CREEK, ss. (Name) ./ (Official DesiB^atioir) (Court or Congrcga^on) of. ,4 iCoiinty, Stato-ef Oklahoma, do hereby certify that I joined in marriage the persona named in ad3 authorized by this License to-ie married, on the. ,day of, (.^•£^-^~^f - --^'- . i A, D., 1&X-6 nf —County, State of Oklahoma, In the presence and My credentials of authority are recorded-in Ministers' Credentials . Record Book , , / (Person Performing Ceremony) at nage~_ of, . , . . —, , .—County, Oklahoma, (Off iciaL-pcsi gna tidn) jicense returmtd, and Certificate of Mairmh-c recorded subjoining the record of License issued and recorded in Marriage Record Book 73 at Pag Cf • ' of . \ //. ^/ . xi on this DOROTHY CRAWFORD, Court Clerk. J>puty  STATE OF-OKLAHOMA ' 2 0 1 3 0 4 . O 0 1 - CERTIFICATE OF DEATH STATE RLE NUMBER 2013-01 8298 11. DECEDENTS LEGAL NAME (First, Middle, Last Suffix] la. LAST NAME PRIOR TO FIRST MARRIAGE 2.SEX RODNEY GLENN BROOMHALL MALE 3. SOCIAL P 4. EVER IN US ARMED FORCES? 5a. AGE- Last binttlay (years) 5b. UfJDER 1 YEAR 5:. UNDER 1 DAY 5. DATE OF BIRTH (Mo/Day/Yr) . NO" - '62 I- • Maims Days Hours Minutes ' ' [ 7; BIRTHPLACE (City and Sbtew Foreign County) Ea.RESIDEfJCE-Slate'; Bb.RESIDENCE-County. . - Bc.RESIDENCE-Cityor.Tqwn ' •. OKLAHOMA - -•' .. ••TTJLSA • SAND SPRINGS ,RES1D£NCe-3pCode '. . RESIDENCE-lnside City Limits? 81. RESIDENCE-Streel and Number 8g.RESIDENCE.Apt. Number . 74063 •'" , " YES '41'2'N LINCOLN AVE [9. MARITAL STATUS ATTIHE OF DEATH. -- " • -'' 10. SURVIVING SPOUSE'S IIAME (II wrfe. gh-_e name prior blifstmamage) D NeverMarried • Q VV-dwed D Divorced D Married,'twtseparaied DUnknown KAREN .LEE-THRESHER- . ' " . . , - 11.FATHER'S NAME (First. Middle. Lasl) ^.'.MOTHER'S NAME PRIOR TO FIRST MARRIAGE [First. MMi, Lasl) JOHN W. BROOMHALL - -GLADYS .BERNICE .SPROWLES A3. DECEDENT OF HISPANIC ORIGIN?. — 14, DECEDENTS RACE •, I 15, DECEDENTS EDUCATION .WHITE "• NO,"NOT:SPANISH/HISPANlC/LAT!NO HIGH SCHOOL GRADUATE OR GED COMPLETED 16.-DECEDENTS USUAL OCCUPATION (Indicate type of wo* done During maa of wcrtng Irtej DO NOTUSE RETIRED. 17. KIND OF BUSINESS / INDUSTRY • . : . - ' ' • . • : • ' FIREMAN - - ' . . SAND SPRINGS FIRE DEPARTMENT Ifla.lHFORMANTSNAME - ' - ' ' • • • m.RELATIONS^PTO DECEDENT 18c. MAILING ADDRESS (Street and Numtwr. Crty, State, Zip CoSe) . KAREN BROOMHALL ' . 412 N1INCOLN AVE/SAND SPRINGS, OKLAHOMA 74063 '19, METHOD OFOISPOSmON;. • ' + ' < • . • • . . . . : 20. PI ACE OF DISPOSITION (Name of cemetery, crematory, other place' 21. LOCATION - City. Town and State G Burial '.' B CrGmatkxi ;'•' LI Donation " D Entombment • '•'""' '.:F.LORALHAVEN;CREMATORY • BRGKEN'ARROW/OKUHOMA -O RerpoVal trorri state ,.•'.'.' • • D O B i e ' ! a'NAWEANDCOMFIETEADDRESSOFFUNEfiMiFACILITY-'! a.-F,UNEPALHOMEDlRECTOR OR FAHB.V MEMBER ACTOJG AS SUCH '••-• . - ' ^ " • • : ' ' • * " ' ' * " : DANIELLE-; j; CARPENTER. 24iEHESTABtKHMENT LICENSE?' -•,-;-:. -1;-'25:Pl JCE QF-DE^Trf (Ojeckr'onfy onei^inrlnctioris)^ •/.'- [ tF DEATH OCCURRED IH A hjOSPJJAL: '. . . . >., IF.DEATHOCCURra^OTHER.THANlHAHOSPlTAL;-' nt D EmergencyRgcm'C^lpaBwt DDead.on"Arrfval'• .-.. D Hospfci.F.acfi J'; D Nur^rKxi^br>gtwnca-8Jradiiyl'"n Decedent's hone . Q 09ier(speaf/): 27 CITY OR. TpWrf:STATE AND ZJR.CCQE OFLOCAflpN-pF DEATH •28. COUNTY OF DEATK : • • ' . TUL'SA :-• I 33, WERE AUTOPSY' FINDJNGS AVAILABLE TO CQMPLET&THE-CAUSE OF DEATH?- . ' • =--,'-V^ L,r'.H-T*CAUSEOF DEATH (See Instrii ' caused I e'deaBi.'Dp fX>T'.enttf'ten;r»tiareyeribsixti as cardiac arrest,' •' . • •Apprbnmate Interval; s coniniiulirx] lodeafibulnol '. DO HOTABBREW]] ii'Ehlerwi^'one causo.on a line.-A^'-addi'twal lines tfnecessary. Onset In'deaUi resulting in tne urxierljing cause given in PART:I: • - . \': ^'-;'^^I*?ii'5:p;f-;';'1("^;'1-4r.:.-y1-'-51'1"" vO'i;-.1. /' DIABETES MELLtTUS. UNKNOWN.- ' " ' 'i HYPERTENSION, CONGESTIVE Jeto(w.asaaxiseqiienceoO;^ v'-': • '-::r'^' ,.-. .!-'/';--*-• ; .>.'-J/-v -i'-'.'V""-.'"V; ''-•'••'.'' '•,-•-•• 'HEART^ULURE, CHRONIC " OBSTRUCTIVE PULMONARY DISEASE - iueto(oras'atofisK]iiericeo():.i,••/*', '".;•' . ,'„;.:; •".._.,.'. • Enter Die UNDERLYING CAUSE (disease Cf'injur/ltelinilialedttie'evenKresulljngin' death)LAST. ' ; "'.'- ' '" • '" •• - • 36,. MANNER Of DEATH*,"?..:/ 37.IFFEWALE:>--,"-."::•.<i1 38. DID TOBACCO USE CONTRIBUTE G' H 01 pregna h t wi Wn past ,y« ' 'TO DEATH? \ • ;- D'rSot pregnant,-b«jt pregnant D Yes Q'fJo' DProbaWy 0 UnVnown 39. DATE OF. If JJUR^. fMa •M);.T)MEOF.IrUURY.. '42..DESCRIBEHOW INJURY OCCURRED: 43, INJURY AT WORK? .il.lbCATIOf) Of WJURY":;. ' Sata,v" 45. IF-TRANSPOfiTATION INJURY, SPECIFY: . D Driver/Operator D Passenger D Pedestrian SireetSMuni&rv' 'C'•">.• ~ ; ' ."' ,47.',NAWE; ADDRESS AND ZIP CODE OR PERSON COMPLETING CAUSE 0^ DEATH (Item 3d) ' •' ' l_\G r^YSjCM^D Pfi^sicSJi In chargejTlhe'Fabenrs care. i r , ;-y-i- • To the best o/ rVry biowlerJ9«;"dMrfi occurrad attlie.tlrnc, dale,-.and place;and due'to'U i!ciiji5(s) and manner as state'd; ' iH'MEpl'f^J-'EX^iNER/Cri'Mt^'soIexarrmsiw.aixyor^ 6cdKredatir«'fma,.ilaie1 "-. , - ' 74107 ".\3 SO; REGISTRAR'S.SISrWTURE- 52. DATE RECEIVED BY.STATE REGISTRAR . •;..'' •" ..JULY 11;2013 . 2008 REVISION. M 'M '•'• T \y 12; 2dH'3 2:28:39 PM