Recorded Certificate of Death Q _ `'"W∎tooIv�jVi.�_-_-*`4U�Di.- "•`•I∎♦i••♦∎•••7" -_`4.10/10/1 bi'-- '`vg∎∎♦•1•♦♦:•Zj�I' --'* a a-
♦ i STATE OF TENNESSEE '- o i�=••�•�♦0 rr*.� ,-,�.°�:
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•5 •• TENNESSEE DEPARTMENT OF HEALTH e.
• ' fi 7 STATE FILE NUMBER fl%
• ea CERTIFICATE OF DEATH :7-
2 SEX 3.DATE OFDEATH(Month,Day,Year) "'
m 1.DECEDENT'S LEGAL NAME(First Middle,Last,Suffix) �,
DECEDENT Dr.Vernon Hutton Young Male January 16,2012
if
4.TIME OF DEATH 5a,AGE-Last 5b.SHEER,I YPAR Sc,UNDER 1 DAY 6.DATE OF BIRTH(Month,Day,Year) 7.BIRTHPLACE(City and State or Foreign
(Approx.) Birthday(Years) Months Days Hours Mmules CovntrY) '/
82 September 30,1929 Sparta,Tennessee
e TYPEIPRINT. 8a,PLACE OF DEATH(Check only one)
IN IF DEATH OCCURRED IN A HOSPITAL IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL F
"s PERMANENT ❑inpatient❑ER/Outpatient❑DOA ❑Hospice facility❑Nursing g facility ❑ ❑ (Specify) '
PERMANENT
INK pica faulit ghome/Lon term care facili X Decedent's home Other residence Other(Speci .�'
8b.FACILITY NAME(If not institution,give street and number) 8c.CITY OR TOWN 8d.COUNTY OF DEATH
7156 Cheshire Drive Knoxville Knox ,x
-4 _ 9.MARITAL STATUS 10.SURVIVING SPOUSE(If wife,give Ila.DECEDENT'S USUAL 11 b.KIND OF BUSINESS/INDUSTRY
T-..k _ ['Married ❑Married,but separated ❑Widowed name prior to first marriage) OCCUPATION
El Divorced 0 Never married ❑Unknown Jeanne Marx Orthopedic Surgeon Ft.Sanders Regional
12.
Tennessee Knox Knoxville .
4 a 13e.INSIDE CITY LIMITS 13f.ZIP CODE 14.WAS DECEDENT EVER IN US ARMED
13d.STREET AND NUMBER
m 7156 Cheshire Drive DYes DNU 37919 FORCES? ❑X Yes DNo
x 17.DECEDENT'S RACE(Check one or more races to indicate what the
15.DECEDENT'S EDUCATION(Check the box that 16.DECEDENT OF HISPANIC ORIGIN?(Check the
best describes the highest degree or level of box that best describes whether the decedent is decedent considered himself or herself to be) :10071. (7 z school completed at the erne of death) Spanish/Hispanic/Latino.Check the'No'box if ❑X Vvhite ❑Vietnamese Q m w ❑8th grade or less decedent is not Spanish/Hispanic/Latino) ❑Black or Afncan American ❑Other Asian(Specify) r n -�2 ❑9th-12th grade;no diploma Q No,not Spanish/Hispanic/Latino ❑American Indian or Alaska Native m = .ZOI y w ❑Native Hawaiian o ❑High srhool Graduate or GED completed ❑Yes,Mexican,Mexican American,Chicano (Name of the enrolled or principal i X
Vibe) ❑Guamanian or Chamorro
❑Some co
credit,but no degree ❑Yes.Puerto Rican ❑Samoan 0, 0 m m -'
1' w ❑Associate degree(e.g.,AA,AS) El Yes Cuban ❑Asian Indian
S ❑Other Pacific Islander(Specify) 0 C _ A
❑Bachelors degree(e.g.,BA,AB BS) ❑yes,other Spanish/Hispanic/Latino(Specify) 0 C X N -A
:Wasters degree(e.g.,MA,MS,MEng,MEd,MSW,MBA) 0 Filipino ❑Other(Speciy) 0 W
['Doctorate(e.g.,PhD,EdD)or Professional degree ❑Japanese -I 0 f �0
(e.g.,MD,DDS,DVM,U.S.JD) ❑Unknown ❑Korean ❑Unknown 0 O Unknown 1❑8.FATHER'S NAME(First,Middle,Last) - 19.MOTHER'S NAME PRIOR TO FIRST MARRIAGE(First,Middle,Last) m A
*, PARENTS John Douglas Young Laura Lee Gillen 0 r_, op
20a.INFORMANT'S NAME 20b.RELATIONSHIP TO DECEDENT 20c.MAILING ADDRESS(Sheet and Number,City,State,Zip Code) �7 m '•
e Jeanne Young Wife 7156 Cheshire Drive Knoxville,Tennessee 37919 a -, co
21a.METHOD OF DISPOSITION OX Burial['Cremation 21b.PLACE OF DISPOSITION(Name of cemetery, 21c LOCATION-City or Town and State O -D
s ISPOSITION ❑Donation ['Entombment ❑Removal from State crematory,other place) fV
Dother(Specify) Highland Memorial Cemtery Knoxville,Tennessee
22a.SIGNATURE OF FUNERAL DIRECTOR 22b.LICENSE NUMBER 220.SIGNATURE OF EMBALMER 22d.LICENSE NUMBER => (.1T
■ Kaitlyn McAdams 6419- ■ Christi Robbins 6425 m G)
23a.NAME AND ADDRESS OF FUNERAL HOME - 23b.LICENSE NUMBER OF FUNERAL HOME 0 m
Highland Memorial funeral Home 5315 Kingston Pike Knoxville,Tennessee 37919 1038 2 ry 73 -,
7. 4►13EGISTRAR'S SIGNATU � ) - 25.DATE FILED(Month,Day,Year)1 tt N 2 7 ZO�L
REGISTRAR � D• . _ JIi C 04 6
26.CERTIFIER(Check only one): (/// '�
CERTIFIER 26a, PHYSICIAN-To the best of my Ifiowledge,death occurred at the date and place,and due to the cause(s)and manner stated. a
PHYSICLAN 26b.0 MEDICAL EXAMINER-On the basis of examination;and/or investigation,in my opinion,death occurred at the date,and place,and due to the cause(s)and manner stated. 0
27e.SIGNATU- F CERTIFIER 27b.LICENSE NUMBER 27c.DATE SIGNED(Month,Day,Year) C
t _ . 17P---2--- r._zc-z /z z)
ECAUSE+c 27d.NAME AND A DRESS
�aEev ito Qr V lw :�.Y -`�'377/G
DEAMPLETE {Vk7ni1%SLilP y �at'f JAI'✓`
no SIGN
.r+o SIGN PART L Effie a phain of eventf(diseases,injures,or complications)that directly caused the death.DO NOT enter terminal events such as cardiac arrest, Approximate neto deathlerval. s.
/VD'4NM respiratory arrest,or ventricular fibrillation without showing the etiology.Enter only one cause one line.
RouRS. /1 • r-. -
IMMEDIATE CAUSE /_, ALL [� �•
_ (Final disease or condition-► a. Lc-•�-ro(�/(�� /''1�-')• G i l(-!r (i i��f,) _
.MEDICA resulting in death) {/ 'Due to(or as a consequence of) /
ERTIFICATION Sequentially list conditions, b.
v
' if any,leading to the cause Due to(or as a consequence of): 9
' listed on line a.Enter the !y'
°,4 UNDERLYING CAUSE c
(disease or injury that Due to(or as a consequence of):
initialed the events resulting d.
in death)LAST
PART 11.Other significant conditions contributing to death but not resulting in the underlying cause given in PART I. 29a.WAS AN AUTOPSY PERFORMED? r i.
rt !1 ((�� ❑Yes ❑No
" V!L2 r? (1'U YrC�\r dy i:'{pr -< f/)))/ di/ 29b.WERE AUTOPSY FINDINGS AVAILABLE TO
,I t ^I 'M1 - COMPLETE THE CAUSE OF DEATH?❑Yes❑No I bm;7'
30.MANNER OF DEATH 31.DID TOBACCO USE 32.IF FEMALE: "
atural ❑Homicide CONTRIBUTE TO DEATH? 0 Not pregnant within past year ❑Not year pregnant,are deatp pregnant 43 days to .
❑Acoitlenl❑Pending Investigation ❑Y s ❑Probably ❑Pregnant et time of death ,):
No ['Unknown ❑Not pregnant,but pregnant within 42 days of death ❑Unknown if pregnant within the past year
❑SW NS ❑Could not be determined t
33.IF TRANSPORTATION 34a DATE OF INJURY 34b.TIME OF 34c.INJURY AT WORK?34d.PLACE OF INJURY-at home,tarn,sheet,factory,office,building,etc.
INJURY,SPECIFY: (Month.Day,Year) INJURY ❑yes ONO (Spey) -
■
�, El Driver/Operator
Ik' ❑Passenger 34e,DESCRIBE HOW INJURY OCCURRED 34f.LOCATION OF INJURY(Street and Number,City or Town,Stale) e,
0 Pedestrian ',
i ° 0 Other(Specify)n
( RDA 1399
P •659(R v.1012011,
m hereby certify the above to be a true and correct representation of the record or document on file in this
1 department.This certified copy is valid only when printed on security paper showing the red embossed seal r-s
6 2 714 2 3 of the •
Tennessee Department of Health.Alteration or erasure voids this certification. Reproduction of this k��'
= document is prohibited, n%�
Tennessee Code Annotated 68-3-101 et seq.,Vital Records Act of 1977.
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� •. Catherine D. t _
.0•• Cate e Haralson,RN, BA John J.Dreyzehner, MD,MPH,FACOEM Date Issued �4 :.'
•fs ACRICU,,e EIA e STATE REGISTRAR COMMISSIONER �ncRrcU, Re I `�'ale
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