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x <br />Report of Death 000002067962 <br />Vital Statistics 25 TAC Sec 181.2(a) "The funeral director, or person acting as such, who assumes custody of a dead body or fetus shall obtain an <br />electronically filed report of death through a Bureau of Vital Statistics system or complete a report of death before transporting the body. The report of <br />death shall within 24 hours be mailed or otherwise transmitted to the local registrar of the district in which the death occurred or in which the body was <br />found. A copy of the completed or electronic filed report of death as prescribed by the Bureau of Vital Statistics shall serve as authority to transport or <br />bury the body or fetus within this state." <br />Print in dark ink the legal name of the deceased as shown on the Social Security card or birth certificate. <br />MARY BLACK BLACK <br />first middle last suffix AKA maiden <br />Date of Death 03 / 09 / 2017 Sex FEMALE Date of Birth 10 / 29 / 1935 <br />month day year month day year <br />Social Security Number 4 5 9- 8 0- 5 9 0 2 ❑ None ❑ Not Available <br />Place of Death (check one) <br />❑ Hospital Inpatient <br />❑ Hospital Emergency Room/Outpatient <br />❑ Hospital Dead on Arrival <br />❑ Hospice Facility <br />Facility Name (If not institution, give street & <br />® Nursing home/Long term care facility <br />❑ Home of Deceased <br />❑ Other (Specify): <br />LEGEND HEALTHCARE & REHABILITATION CTR. <br />City, Town, or Precinct Number County <br />PARIS LAMAR <br />Local registration office for the area where this death occurred: REGISTRAR - CITY OF PARIS <br />❑ This death may be due to homicide, suicide or accident; or this death occurred without <br />medical attendance. Check One <br />This death will be certified by: ® Physician ❑ Medical Examiner ❑ Justice of the Peace <br />Name and address of certifier: <br />GORDON STROM <br />4025 HOLBROOK <br />PARIS, TX 75462 <br />Name and address of person making this report (if funeral director list license number and <br />funeral home): <br />Signature or electronic verification of person making this report Date of report <br />The Report of Death may be mailed, faxed, emailed, electronically registered or conveyed in <br />person. A copy of this document is to accompany the body. This report contains confidential <br />information. <br />VS -115 Revised 9/2004 (may be duplicated) <br />Date /Time Received <br />Report <br />Certificate <br />Electronic <br />Registrar Use Only <br />