a Dem. 
53/, KENTUCKY CERTIFICATE OF DEATH
- riff Lam w?mmw?mmww? I

Derrick Ray Rose

 

FEMALE. 
MARRIAGE

N6. 5816

116
zsax' 
Male

P.2

 

70 FIRST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

?momma: DATE OFIIEATH 4. AGE-LAST . . mm 
WI, mum - fofW-ficu?iw'  ig?io?er%% a 17. CI. OF DEATH
Sept. 20, 2010 25. Boone
6. PLACE OF DEATH (Shankanb'me)
- Harmm? Emmy! mammal omen; CI Haag'ea Facimy himlng H091me Term Care FILL-duly Residmu Irv-meow
Ia. m:me NAME (rum gum-mum 10. CITY 0R TOWN. STATEAND can:
St.?EllZabeth Florence FlorenCeiKY 41042
11.5111um nu ma sum: Fenian mm Ia MARITAL STATUS 18. SURVIVING spans: aqua-um mm mm MI My?)
. Widowed DEW Married
I IN Divorced (3 mm .
14. DECEDEHTS uswu. OCCUPATION mm ?mm any mustarme In.) 16. KIND OF BUSINESSIINDUSTRY m. WAS DECEDENT EVER IN us.
pa mm MM) ARMED 
?Eaborer Construction mm, 
178. RESIDENCE 8m: 1711. COUNTY 17:; CITY ORTOWN I 176. STREET AND NUMBER A 3 17?. CODE 17f. INSIDE cm'
. . 
Kentucky Grant Maln St. 41097 Kh? UM
1a. EDUCATION 19. OF HISPANIC (am he mum RACE
thmIMqummuu?w?d-qmu-Md Mumormn mMWuhw?bh)
?mum ?mumd?w mgama 'No?loxifm manian mm? m? 5'an
8" Grade ?Loss No, ma. aIInu Birgit human mun E1 mm
9?42" Grade; No 0W Yes, mm Madam Anna-imam, .
19h 5m Gram or GED (Ide Puma Rm . (33:35am Hand:-
b? '3 :1 FIIpho Amman Indian I:er Native
Amanda Benn? (3.9.. A3) Yns, min-r [j JWW (Mama was tr W, m)
Bachelor: Dogma (9.9., BA. A8, 38) 0? memo . .
- m? 
9. .. NO 9.9..
muons! 03M, LLB, J0) ?mm 
21. NAME (HM m. we 22. WE PRIOR To FIRSTMARRLAGE (mgmmum
Tommy (NMI) Rose . Kathy (NMI) Winkle
238. NAME TO DEOEDENT 23c MAILING ADDRESS gum: ?munch, am. ugcm
.Kathy Richards Mother :unflower Dr., Cabot, AR., 72023

 

 

 

24. OF DISPOSITION (Chad; ashram}:
trial Gunmen Dvarndim Entanme
Removal Iwm SH: El 0810! (Spawn

 

25. me OF DISPOSITION ?our-um;

I.0.0.F. Cemetery

 

 

26. Town and sun

Carrollton, KY 41008

 

To Be Completed By; F?imaral Director {Must Be Typed}

 

 

 

 

 

 

33. PARTL Barnum-MAW
no

3  35 0F FUNERAL 55mm: LICENSEE mm mug um Imam 23 LICENSE NUMBER 23. AND COMPI. ADDRESS OF FUNERAL 
?Wm Mkmw? Ing?ymEck er?Riley F.H., Inc.
gg??g_xy?5510 Ave-
?mu I ICarrollton? KY 41008
30. DATE DEAD Manama 31. ACTUAL on panama; TIME or DEATH 32. WAS MEDICAL EXAMINER (m CORONER comm?
September 20, 20K) 9:20 P.M. gm DMD 
muss or mm W?mema?? Lima


NOTABEREVIME. ErWonIvmnmonu?: ?aw. . 

 

MATE ?ind an?. a . . .
Anoxlc bran-1 injury

FIT: m? ?(on As' A oo' mam?"?03:
Sequentiin mammary. Hanging

 

 

wmuummu cause
Mom-1M Ilwuumu


hadhgiothecsuso IImdon?n-a. MfomuAmEqumcgon

 

a



 

 

 

To Be Completed By: medical?cer??ar

a.
PARTIL 

34, HAMMER 0F EEATH
Naiural Accident
Homicide Pending Inm?gauon

 

 

 

 

    

 

 

     

 

 

 

TL 
Hanging by bed sheet: froIn 

:36. TO BE COMPLETED BY 

Suicide El (mule nolbe Detemlinad
3K AUYOPSY 31. USE EB. IF FEMNEwens CI . [3 regnam-luqaofdemh.
36' To Yes Probany Nat mam-IL wiIhh 42 shy: (Main 13 Linkmm i? mananl wahn pan} year
Yes I: Na 2an CHIN 
39. DATE OF glu- I URY 41. INJUR AT WOR 42. MEPF INJURY (?umm'tm 43. EF INJURY, 
MM a  :3 ?mm nomwummw.
September 18. 2010 - A .N I :1 You De tgntion Center Pa :1 am. Each)

 

ailing vent -212 B?rnes



DATE EMU?Whaman

 

 

Road Williamstown. KY 4L097
October ?,'2010

 

 

 

 

 

W, sums 

 

.  Ihoaam ?(in?rm ?mdm?mof?a?mshm - ?w
Tubmanwu?d:   
comm DEA Human) 
. ?thv Coroner 7500 Highway 42 Florence, KY 41042- -
Dauglas Sta. 9 A I amamewmq .