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DEPARTMENT OF STATE HEALTH SERVICES

VITAL STATISTICS UNIT


TEXAS DEPARTMEN T OF STATE HEALTH SERVICES - VITAL STATISTICS
JAN 23 2015
1 LEGAL NAME OF OECEASEO llndudo N<A's. U an,1 IF'nl. ..-. I.al)l
I
JAMES HENRY STON E
,1 - DATE OFBIRlH (mm-o:tyyyy) I AGE-Last Binhday
3.SEX
(Y
1
APRIL 22 1982
32
MALE
l """I
ALSTATUSATnMEOFOEATH
7.ALSECURITYNUMBER

STATE OF TEXAS

CERTIFICATE OF DEATH

1oa. RESIDENCE STREET ADDRESS

18

1F1woiaA 1 YR

I oa,.

Mo
O Manl8d

D Wclo- D - l'i,l Na.......... D Unknown

142-15-007851

2. DATE of DEATH ACnlAL OR PRESUMED


'JAN UARY 19 2015
B. BIRTHPLACE (City & Stm11 ' Foreign Coa.nuv>
MOUN TAIN HOME AR
9. SURVIVING --.........E'S NAME (II wile, QMI name priDI IO ltrSC maniagul

,_,,,,,

!'Ob.APT NU,

10l.ZIPCOOE
1
n301
12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE

IQe. STATE
I
TEXAS

MONTGOMERY
11. FATHER'S NAME

STATE FILE NUMBER

10c. CITY OR TOWN

CON ROE
10g.INSIDE CITY LIMITS?
1 181Yos
0No

JOAN MCGIN NIS


WALLACE FRANKLIN STON E
13. PlACE OF DEATH (CHECK ONLY ONE)
11F DEATH OCCURRED SOMEWHERE OTHER TJ-W,l A HOSPITAL.
IF DEATH OCCURRED IN A HOSPrrAL
I O ........ F-v
ONuRlnn tm>I
l'i,l Decadlol'> tm>o
O Otho, (Splcilvl
O Iopa!- 0 ER.Ou"'""
0OOA
,s l,;IIYIIVWN, Dt" tlF ...... ,..-..,.;uTYUt.UT M:PRECIHCTNOI ,e. FACILITYNAME(llnol insllution,QCWSUNIDddrMSS)
14.COUNTY OF DEATH
.::
,
,
MON TGOMERY
,
CON ROE n301
17 INFORMANT"S NAME & RELA'1JUMM1IP TO DECEASED
18. MAILlNG ADDRESS OF IN
C
P Code)
1
JOHN ALLEN HOSKINS V - SIGNIFICAN T OTHER
CON ROE TX n301
20.
SE
Of -.....
-..-- u,n,..,... UH -.an.n.n-. 21.
19 METHOD OF DISPOSITION
ACTING AS SUCH
Ctemalmn
O Ootultioo
0&,nal
Sec101 ________
' D Entom"""""
o--CORA LEE MCLEAN ,BY ELECTRONIC SIGNATURE O au,., 1-1
11ccc2
10N, "1c"';::.,1 To;;,: :::..,::-,-:::-::,-..:,sw;:;,1, ,---------lL01
::cry:c.-::aoma=::::IOIY::::-:,...,=,-::;p1oa1;::!:!,1f-!-2=;_-.-.,.23,-;.......,.""',.T"""
'" =1"'11ome="'o1"'com=...
l..22li''a:
. PLACE:o.sl1Fo,,,,..,.,,S""ITION
5paca
s. MCNUTT BROCK CREMATORY
CON ROE TX
25. COMPLETE ADDRESS OF FUNERAL FACILITY (StnNM and Number, Clly, Stnta, Zip CodeJ
24.NAME OF FUNERAL FACILITY
{
1600 PORTER ROAD CONROE, TX 77301
.5 MCNUTT FUNERAL HOME
; 26. CERTIFIER ( only one)
O Co,dying pnpidan-To ,-NS o1 mr i..nowi.dgu, d8illtl DIXUINd "' 10.,. c:.wse(s) and rNtM8I staled.
(8l Modal Eaunimd.Jusllcu of ine Puce. On lhu basil OI ard'ot In my opnion, tlCCWNd at Iha time.dale Mid plMat. Id dull ta hi CM&Sl.'(S) ..00 INll'V"1f liuued,
28. DATE CERTIFIED (rnnHSd-yyyyt 211. LA-EN::u: NUMBER ,30. TIME OF DEATH(Aclual Of prnumed)
! 27.TUREOF CERTlflER
,
JAN UARY 22 2015
jj WAYNE'L MACK BY ELECTRONIC SIGNATURE
12:14 AM
32. TnLE OF CERTIFIER
_ 31. PAINTED NAME. ADDRESS OF CERTIAER (SlrHI and Numblll, Clily,Stale.Zip Cadet
-::: '-.
I
,
JP
WAYNE L MACK 19380 HWY 105 W. STE 507, MON TGOMERY, TX n356
.5 !
Approaimale intorval
33. PART 1 . ENTER THE CHAIN Of EVENTS - DISEASES, NJU
l RIES, OR COMPUCATKlNS - THAT OIRECTLY CAUSED THE DEA TH QQ.lQ! ENTER
Onsal to death
;j U
TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTfUCULAR ABRIU.ATION wtTHOUT SHOWING THE
.X
ETIOLOGY. 00 NOT AIIBREVIATE. ENTER ONLY ONE CAUSE ON EACH.

...0Ii

I:
r,

IMMEDtATE CAUSE (Final


! x resuling
....... condolion->
:_ i i In dNlh)

'

G!.---------------------------N
a.HAN
Gl
0"8 IO (DI U aconsaquenc:e af):

":t,':!' ----------------------------------
ti
,
:
,
-=i UNOERL
lisled on tnaL Enlar Iha
YING CAUSE
\
,
----------=---,--------c:-----------------Oue lO (or as acon of):
.Iii 5 :::::a
in daa!hl LAST
Oua

con.equonco ol1

.e:

il if CAUSE
PAJIf 2.
I UIn SfGNIFIC CQN91T19NS CONJRIBUJINOffiPEATH BUT NOT RESULTING IN THE UNDERLYING
GIVEN IN PART L
o;;i-., laO'

';

37 Dill TOBACCOUSE
TO DEATH?
D Yes
0No
O Prullllbf/
ISi Unknown

34 WAS AN AUTOPSY PERFORMED?


0No
181Yus
35. WERE AUTOPSY FINDINGS AVAILABl..E TO
COMPLETE THE CAUSE OF DEATH?
0,Yes ONo
39 IF IHAN:)t"UMIAu.m INJURY,
SPECIFY
D eriw,IOpomto<
O P.iuangar

"'PV' '- 38. IF FEMALE.


ONol pragnm11 wctm past year
O Pregnant al tme at d8a&h
ON.............. ...,.,.,. ..........,. .........
ONot pregnant. bul pr8'JWll "3davs 1a one Y'N' bekJl8 doAlh
D 0111url5poa1,1
O Unknown Mix...- ......... pas1,TIME OF INJURY 4Dc. RY AT woRK?
40I. DATE OF INJUAY(mm-dd-yyyy)
Pl.ACEOF INJUAY (e.g. OIIC8denrt hOme, c:or1ilrudiOl1 5168. r. wooded 1
a N)
"I
r D Y
lSI No I BEDROOM
JANUARY 19, 2015
12:14 AM
40e. U,K..;ATION tStrNl and Number, Cll.y,S&ale,Zip Code)
4IM COUNTY OF IN.KJRY
36. MANNER OF DEATH
D Nat<Hlll
D Aa:idlnl
lSISwade
D HormoOe

l.,Uf'I ,

g ::::.:.:....

l'"(I).

Gj
CON ROE TX n301
a: 41 DESCRIBE HOW ll<JURY OCCURRED

"'

HANGED SELF
en 42a. REGISTRAR ALE NO.
01-0139
FAA NI WRER nnmnu;.,1.:uu

l"Od.

2c. REGtstRAR REGISTRAR - MONTGOMERY COUNTY CLERK,


1
ELECTRONICALLY FILED

AMENDMENT TO CERTIFICATE OF DEATH

VITAL STATISTICS
Texas Department of State Health Services
RECORD ID. REGISTRANl'S FUU. NAME AS SHCJVtlN ON DEATH CERTIFICATE
JAMES HENRY STONE
PLACE OF DEATH COUNTY
CORRECTION

ABSTRACTs

CERWICATION

MONTGOMERY
ITEM OR ITEM NO
1.
8.
9.
17.

tTYORTOWN

CONROE
ENfflY ON CERTIFICATE

---

JOHN ALLEN HOSKINS V - SIGNIFICANT OTHER

TYPE OF OOCUMENT

DEATH NO
007851
DATE OF DEATH
01/1912015

CORRECT INFORMATION

JAMES HEN RY STONE


N EVER MARRIED

AFFID OF INFORMAN T, JOHN ALLEN


STONE-HOSKIN S, V
COPY OF COURT ORDER, CAUSE NO.
SA-13-CA-00982-0LG

OR'.';'.TRY
07/09l2015 )
08/0512015

JAMES HEN RY STONE-HOSKINS


MARRIED
;, .JOHN ALLEN STONE-HOSKINS, V
UOHN ALLEN STON E-HOSKIN S, V - HUSBAND

BY WiOM lSSUED ANO SIGNED

BOBBY LEE NOVAKOSKY, N OTARY


PUBLIC, STATE OF TEXAS
UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF
TEXAS, SAN ANTONIO DIVISION

IHeREiiY trnnFY THAT I HAVE EXAMWEO THE DOCUMENTS LISTED ABOVE ANO THAT THE ABSTRACT IS TRUE AND CORRECT

DATE FILED
VS-173 REV. 9/94

MONTGOMERY

42b. DATE RECEIVED DY LOCAL REGISTRAR


1
JANUARY 22. 2015

>

o-oan

OB/06/2015
STATE REGISTRAR
Texas Department of State Health Services - Vital Stabstlcs

DATE Sl SUEO

08/06/2015

08/0512015

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