STATE OF TEXAS CERTIFICATE OF DEATH STATE FILE NUMBER

1. LEGAL NAME OF DECEASED (Include AKA's, if any) (First, Middle, Last) (Maiden) 2. DATE OF DEATH - ACTUAL OR PRESUMED

JONATHAN KAMAU THUKU WANGUI Jan 19, 2024

TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS UNIT

3. SEX 4. DATE OF BIRTH 5. AGE-Last Birthday IF UNDER 1 YR IF UNDER 1 DAY 6. BIRTHPLACE (City & State or Foreign Country)
(Years) MO DAYS HOURS MIN
Male March 23 1994 30
7. SOCIAL SECURITY NUMBER 8. MARITAL STATUS AT TIME OF DEATH 9. SURVIVING SPOUSE'S NAME (If Wife, give name prior to first marriage)
✔ Married
Widowed Divorced Never Married Unknown
467963854 Whitney Pearl
10a. RESIDENCE STREET ADDRESS 10b. APT. NO. 10c. CITY OR TOWN

10d. COUNTY 10e. STATE 10f. ZIP CODE 10g. INSIDE CITY LIMITS?

SAN ANTONIO TEXAS TX 78205 ✔ Yes No

11. FATHER'S NAME 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE

13. PLACE OF DEATH (CHECK ONLY ONE)

IF DEATH OCCURRED IN A HOSPITAL: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
✔ Inpatient ER/Outpatient DOA Hospice Facility Nursing Home Decedent's Home Other (Specify)
14. COUNTY OF DEATH 15. CITY/TOWN, ZIP CODE (If outside city limits, give precinct no) 16. FACILITY NAME (If not institution, give street address)

DALAS IRVING 75060 BAYLOR MEDICAL CENTER

17. INFORMANT'S NAME & RELATIONSHIP TO DECEASED 18. MAILING ADDRESS OF INFORMANT(Street and Number,City,State,Zip Code)

FRIEND 2958 Park Square Drive #101- IRVING TEXAS 75060

19. METHOD OF DISPOSITION 20. SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON 21. Unknown
✔ Burial Cremation Donation ACTING AS SUCH Section
Entombment Removal from state Block
Other (Specify)
Lot
22. PLACE OF DISPOSITION (Name of Cemetery, crematory, other place) 23. LOCATION (City/Town, and State)

Old San Antonio San Antonio, Texs Space

The penalty for knowingly making a false statement in this form can be 2-10 years in prison and

24. NAME OF FUNERAL FACILITY 25. COMPLETE ADDRESS OF FUNERAL FACILITY (Street and Number, City State, Zip Code)

Hilliad Funeral Home 129 S. O,Connar Rd, Irving 75060

26. CERTIFIER (Check only one)
Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
Medical Examiner/Justice of the Peace - On the basis of examination, and/or investigation, in my opinion, death occurred at the time,date and place, and due to the cause(s) and manner stated.
27.SIGNATURE OF CERTIFIER 28. DATE CERTIFIED (Mo/Day/Yr) 29. LICENSE NUMBER 30. TIME OF DEATH(Actual or presumed)

Jan 20, 2024 E 1059 4:50PM

31. PRINTED NAME, ADDRESS OF CERTIFIER (Street and Number, City,State,Zip Code) 32. TITLE OF CERTIFIER
a fine up to $10,000. (Health and Safety Code, Sec. 195, 1989)

Alan B. Mickish., M.D 122 Village Shopping Center, Irving M.D

33. PART 1. ENTER THE CHAIN OF EVENTS - DISEASES, INJURIES, OR COMPLICATIONS - THAT DIRECTLY CAUSED THE DEATH. DO NOT ENTER Approximate interval
WARNING

TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE Onset to death
ETIOLOGY. DO NOT ABBREVIATE. ENTER ONLY ONE CAUSE ON EACH LINE
CAUSE OF DEATH

IMMEDIATE CAUSE (Final

a.
Cardiac Arrest Immediate
disease or condition ------>
resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b.

Myocardia Infarction Immediate
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that c.
Coronary Artery Disease long Standing
initiated, the events Due to (or as a consequence of):
resulting in death) LAST

d. Diabetes
PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING 34. WAS AN AUTOPSY PERFORMED?
CAUSE GIVEN IN PART I.
Yes No
35. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH?
Yes No
36. MANNER OF DEATH 37. DID TOBACCO USE 38. IF FEMALE: 39. IF TRANSPORTATION INJURY, SPECIFY:
Natural CONTRIBUTE TO DEATH? Driver/Operator
Not pregnant within past year
Accident Yes Passenger
Pregnant at time of death
Suicide No Pedestrian
Not pregnant, but pregnant within 42 days of death
Homicide Probably Other (Specify)
Not pregnant, but pregnant 43 days to one year before death
Pending Investigation Unknown
Unknown if pregnant within the past year
Could not be determined
40a. DATE OF INJURY (Mo/Day/Yr) 40b. TIME OF INJURY 40c. INJURY AT WORK? 40d. PLACE OF INJURY (e.g, Decedent's home, construction site, restaurant, wooded area)
Yes No
VS-112 REV 1/2006

40e. LOCATION (Street and Number, City,State,Zip Code) 40f. COUNTY OF INJURY

41. DESCRIBE HOW INJURY OCCURRED

42a. REGISTRAR FILE NO. 42b. DATE RECEIVED BY LOCAL REGISTRAR 42c. REGISTRAR

INFORMATION ON BACK OF THE FORM MUST BE COMPLETED IF APPLICABLE

- - - - - - - - - - - - - - - - - INFORMATION BELOW IS FOR STATISICAL PURPOSES ONLY AND IS NOT TO BE INCLUDED ON CERTIFIED COPIES - - - - - - - - - - - - - - - -
43. DECEDENT'S EDUCATION (Check the box that best describes 44. DECEDENT OF HISPANIC ORIGIN? 45. DECEDENT'S RACE (Check one or more races to indicate what the
the highest degree or level of school completed at the time of (Check the box that best describes whether decedent considered himself or herself to be)
death) the decedent is Spanish/Hispanic/Latino. White
Check the "No" box if decedent is not
8th grade or less Spanish/Hispanic/Latino) Black or African American
American Indian or Alaska Native
No, not Spanish, Hispanic/Latino (Name of the enrolled or principal tribe)
9th - 12th grade, no diploma
Asian Indian
High school graduate or GED completed Yes, Mexican, Mexican American, Chinese
Chicano Filipino
Some college credit, but no degree
Japanese
Yes, Puerto Rican Korean
Associate degree (e.g., AA, AS)
Vietnamese
Bachelor's degree (e.g., BA, AB, BS) Yes, Cuban Other Asian (Specify)
Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Native Hawaiian
Yes, other Spanish/Hispanic/Latino Guamanian or Chamorro
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, Samoan
DVM, LLB, JD) (Specify) Other Pacific Islander (Specify)

46. EVER IN U.S. ARMED FORCES? Yes ✔ No 47. EVER A PEACE OFFICER IN THIS STATE? Yes ✔ No Other (Specify)
48. DECEDENT'S USUAL OCCUPATION (Indicate type of work done during 49. TYPE OF BUISNESS/INDUSTRY
most of working life. DO NOT USE RETIRED)
Nurse Health
 IF DECEASED SERVED IN U.S. ARMED FORCES, FILL OUT THE FOLLOWING:
Is the deceased reported to have been in such service? Name of organization in which service was rendered?

Serial number of discharge papers or adjusted service certificate? Name of next of kin or of next friend?

James Smith
Post Office Address?

Instructions for Filing a Texas Certificate of Death

All information except signatures should be typed. If it is not possible to type the information, print
legibly using durable black or blue ink. All signatures must be handwritten in durable black or blue
ink (unless signed electronically in Texas Electronic Registrar described below). Rubber stamps or
facsimile signatures are not permitted [HSC §191.025(d)] for funeral directors and certifiers.
Complete each item following the requirements for that specific item. These instructions can be
found online at www.dshs.state.tx.us/vs/fie/d/handbooks/deacont.shtm or in the Texas Vital Statistics
Handbook on Death Registration.

Do not leave a space blank unless specifically instructed to do so. Avoid using correction fluid. Do
not make alterations, erasures, or strike-overs. Obvious changes affect the validity of a certificate.
Altered certificates may be rejected by the local registrar or Texas Vital Statistics. Avoid
abbreviations except for those suggested in the item-by-item specific instructions. Verify the spelling
of all names and numbers with the informant.

A Certificate of Death must be filed within ten (10) days of the date of death for every death in
Texas. It must be filed with the local registrar in the district where the death occurred or the body
was found [HSC §193.003(a)].

The Certificate of Death must be filed by the person in charge of interment or disposition, or by the
person in charge of removing the body from the registration district for disposition [HSC § 193.002].

The certifier is responsible for verifying the date of death in Item 2 and completing the medical
certification portion of the Texas Certificate of Death (Items 26 through 39). The certifier must
complete the medical certification not later than five (5) days after receiving the record or provide
notification to the funeral director, or person acting as such, explaining the reason for the delay [HSC
§193.005(b)(g)].

If the manner of death is other than natural, the justice of the peace or medical examiner should be
called immediately. Physicians should not certify suicides, homicides, or accidental deaths. A
medical examiner should also be notified if a death occurs within 24 hours of admission to a hospital
(regardless of the manner of death).

A current death certificate can only be filed within one year of the date of death. If a death certificate
has not been filed within one (1) year, a Court-Ordered Delayed Certificate of Death should be filed.

If the cause of death is pending investigation, the certifier should enter "Pending Investigation" and
file the certificate immediately. Upon determination of the cause of death, an Amendment to Medical
Certification of Certificate of Death (VS-174) should be filed by the physician, medical examiner, or
justice of the peace who originally certified the death.

TEXASElectronic
REGISTRAR
TER (Texas Electronic Registration) - Death is a free online Internet death registration system available through the
Texas Vital Statistics office. A user can start and complete his or her portion of the Certificate of Death without having to
leave the office or wait for the other parties to complete their portions.

Licensed funeral directors, physicians, justices of the peace, medical examiners, and local registrars may complete their
portion of the Certificate of Death and electronically sign it at their own computer. Timeliness prompts will warn users to
complete their portion so that the Certificate of Death will be filed in a timely matter. The Social Security number of the
deceased is verified by the Social Security Administration in real-time. A Report of Death is sent electronically to the
local registrar and funeral directors may print a paper copy of that report for themselves.

More information on participating in online death registration is available at: www.dshs.state.tx.us/vs/edeath

. or contact
the Texas Vital Statistics office at 888-963-7111 ext.3303.