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C E R T I F I C A T I O N O F D E A T HSTATE FILE NUMBER: 2013150651D E C E D E N T I N F O R M A T I O N

N A M E : S T A N L E Y S T E V E N S O N

DATE ISSUED: March 30, 2015STATE 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 SBIRTHPLACE: CHICAGO, ILLINOIS, UNITED STATES

DATE OF DEATH: October 30, 2013DATE OF BIRTH: July 19, 1936P L A C E O F D E AT H : I N PAT I E N TFACILITY NAME OR STREET ADDRESS: VETERANS ADMINISTRATION HOSPITAL PALM BEACHLOCATION OF DEATH: WEST PALM BEACH, PALM BEACH COUNTY

SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATIONM A R I T A L S T A T U S : D I V O R C E DSPOUSE (IF FEMALE. MAIDEN NAME): NONERESIDENCE: 13435 CROSSPOINTE DRIVE, PALM BEACH GARDENS, FLORIDA 33418, UNITED STATES COUNTY: PALM BEACHOCCUPATION, INDUSTRY: MILITARY CAREER, UNITED STATES AIR FORCER A C E : W h i t e X B l a c k O f A f r i c a n A m e r i c a n A s i a n I n d i a n C h i n e s e F i l i p i n o N a t i v e H a w a i i a n J a p a n e s e K o r e a n

A m e r i c a n I n d i a n o r A l a s k a n N a t i v e T r i b e : V i e t n a m e s e O t h e r A s i a n :G u a m i a n o r C h a m o r r o S a m o a n O t h e r P a c i fi c I s l : O t h e r U n k n o w n

HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC/HAITIAN ORIGINE D U C A T I O N : A S S O C I A T E D E G R E E E V E R I N U . S . A R M E D F O R C E S ? Y E S

P A R E N T S A N D I N F O R M A N T I N F O R M A T I O NF A T H E R : F E L I X S T E V E N S O NM O T H E R : E L I Z A B E T H T A T U MINFORMANT: SELENA STEVENSONR E L AT I O N S H I P T O D E C E D E N T: D A U G H T E RINFORMANTS ADDRESS: 13435 CROSSPOINTE DRIVE, PALM BEACH GARDENS, FLORIDA 33418, UNITED STATES

P L A C E O F D I S P O S I T I O N A N D F U N E R A L F A C I L I T Y I N F O R M A T I O NP L A C E O F D I S P O S I T I O N : S O U T H F L O R I D A N AT I O N A L C E M E T E R Y

LAKE WORTH, FLORIDAM E T H O D O F D I S P O S I T I O N : B U R I A LFUNERAL DIRECTOR/LICENSE NUMBER: TERRY PLATTS, F042754F U N E R A L F A C I L I T Y : V E T E R A N S F U N E R A L C A R E I N C F 0 4 0 0 0 2

15381 ROOSEVELT BLVD, CLEARWATER, FLORIDA 33760

M E D I C A L E X A M I N E R C A S E N U M B E R : N O T A P P L I C A B L EC E R T I F I E R I N F O R M A T I O N

T Y P E O F C E R T I F I E R : C E R T I F Y I N G P H Y S I C I A NTIME OF DEATH (24 hr): 1605C E R T I F I E R ' S N A M E : M I C H A E L A S I LV E R M A NC E R T I F I E R ' S L I C E N S E N U M B E R : M E 2 6 5 9 0NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT APPLICABLE

C A U S E O F D E A T H A N D I N J U R Y I N F O R M A T I O NP R O B A B L E M A N N E R O F D E AT H : N AT U R A LCAUSE OF DEATH - PART I - and Approximate Interval: Onset to Death:a P N E U M O N I A

b D Y S P H A G I A

C D I A B E T E S M E L L I T U S

PART 11 - Other significant conditions contributing to death but not resulting in the underlying cause given in PART I:A R T E R I O S C L E R O T I C H E A R T D I S E A S E / PA R A LY S I S O F S C I AT I C N E R V E

A U T O P S Y P E R F O R M E D ? U N K N O W ND AT E O F S U R G E R Y:R E A S O N F O R S U R G E R Y :

IF FEMALE. NOT APPLICABLED AT E O F I N J U R Y: N O T A P P L I C A B L EL O C AT I O N O F I N J U R Y:D E S C R I B E H O W I N J U R Y O C C U R R E D :

P L A C E O F I N J U R Y:IF TRANSPORTATION INJURY. Status of Decedent:

A U T O P S Y F I N D I N G S AVA I L A B L E T O C O M P L E T E C A U S E O F D E AT H ? U N K N O W ND I D T O B A C C O U S E C O N T R I B U T E T O D E AT H ? U N K N O W N

TIME OF INJURY (24 hr) I N J U R Y A T W O R K ?

Type of Vehicle:

.State Registrar R E Q : 2 0 1 5 8 0 7 5 4 7

W A R N I N G ;

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 GREATSEAL OF THE STATE OF FLORIDA. DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATERMARKS. THE DOCUMENT FACE CONTAINS A MULTICOLORED BACKGROUND, GOLD EMBOSSED SEAL. ANDTHERMOCHROMIC FL. THE BACK CONTAINS SPECIAL LINES WITH TEXT THIS DOCUMENT WILL NOT PRODUCEA C O L O R C O P Y.

DH FORM 1947 (11/11)

CERTIFICATION OF VITAL RECORD:S i H E A L Tf f