0858032 COMWMONELTH 0F VIR

DEPARTMENT OF HEALTH DIVISION OF VITAL

GINIA

RECORDS

COMIVION WEALTH OF VIRGINIA - CERTIFICATE OF DEATH

 

 

 

 

 

DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS - RICHMOND

 

 
  

 
  

 

DATE RECORD FILED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


9. STREET ADDRESS (INCLUDE HOUSE APT. OR NO.)

 

 

 

 

STATE FILE NUMBER
JANUARY 17, 2017 17-003928
I. FULL NAME OF DECEDENT (middle) (1m) (suf?x)
MU HANIIVIAD ASHRAF SHAH
2. SEX 3. DATE OF DEATH 4. DATE OF BIRTH 5. AGE IP UNDER I YEAR IP UNDER I DAY
MALE .- FEMALE . . NOT DETERMINED AcruAL PRBSUMHD Mm.? D'y' Mm"
JANUARY 16, 2017 DAPPROXIMATB DFOUND MAY 20, 1952 64
6. WAS DECEDENT EVER IN US. ARMED PORCESI 7. (US STATE OR POREION COUNTRY) s. SOCIAL SECURITY NUMBER IF NO SSN, Q-IECK APPROPRIATE Box
YES [if] UNKNOWN PAKISTAN 228 - 79 - 1 735 NONE NOT OBTAINABLE UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. MARITAL 

ELECTRICAL TECHNICIAN

Io. CITYORTOWNOPRESIDENCE INSIDE CITY OR TOWN 
6314 THONIAS DR SPRINGFIELD El YES EINO
II. COUNTY OF RESIDENCE (it independent city, leave blank) 12. STATE (OR FOREIGN COUNTRY) OP DECEDENT-S RESIDENCE ZIP CODE
FAIRFAX COUNTY VIRGINIA 221 50
?11 DBCEDENT (CHECK ONE OR MORE) AMERICAN INDIAN OE ALASKAN 

WHITE BLACK OR AFRICAN AMERICAN [j FILIPINO KOREAN [3 OTHER PACIPIC 

[3 ASIAN INDIAN CHINESE [j SAMOAN VIETNAMESE OTHER ASIAN SOUTH ASIAN

NATIVE HAWAIIAN OUAMANIAN OR CHAMORRO JAPANESE UNKNOWN OTHER (SPECIFY)

I4. DECEDENT 0P HISPANIC ORIGINI

NON-HISPANIC [3 CENTRAL OR SOUTH AMERICAN CUEAN MEXICAN El PUERTO RICAN OTHER (SPEGFY) UNKNOWN

15- EDUCATION (?1933? comma-ED) (0-12) BEIGE SCHOOL DIPLOMA [j GED YEARS OF COLLEGE 4

[j ASSOCIATEDEGREE DEGREE DEGREE DEGREE [1 UNKNOWN

16. CITIZEN OR WHAT COUNTRY II. USUAL OR LAST OCCUPATION Is. KIND OF BUSINESS OR INDUSTRY

UNITED STATES OF AMERICA

 

UNEVERMARRIED

MARRIED WIDOWED DIVORCED SEPARATED UNKNOWN
21. FULL NAME OF FATHER OR PARENT 

name,if any)

 

FATEHDIN AWAN

23. RETATIONSHIP OR SOURCE OF INFORMATION

 

,su?ix) (mu?dcn namle any)

221. GENDER

FEMALE

 

 

SON 

 

25. NAME OF HOSPITAL OR INSTITUTION OF DEATH (if none, to state)

 

PRIVATE
20. IF MARRIED, SEPARATED OR WIDOWED. NAME OP SPOUSE (if divorced leave blank)
21; GENDER 22. FULL NAME OP DBCEDENTS MOTHER 0R PARENT I(nm,mlddIc,Im
MALE 0 OR BIBI
24. FULL NAME OE INFORMANT OR NAME OF SOURCE
JANIAL AWAN

 

(RESTON HOSPITAL CENTER

26. SPECIFY IF DEATH OCCURRED SOMEWHERE OTHER THAN 

DOA



 

25a. SELECT ONEIF DEATH OCCURRED IN 

OUT EMER RM

INPATIENT

 

DHOSPICE FACILITY
21. CITY OR TOWN OP DEATH

[3 NURSING HOME

CARE FACILITY DECEDENTS HOME CORRECTIONAL FACILITY
23. STREET ADDRESS OR RT. NO OP PLACE OF DEATH

OTHER (SPECIFY)

 

RESTON

 

 

 

28L ZIP CODE

 

28h. COUNTY OF DEATH (ifindependenl city, leave blank)

 

 

REMOVAL FROM STATE KNOWN, PLEASE ALSO CHECK FINAL METII
30. PIACE OFDISPOSITION - NAME OF MY OR CREMATORY

 

OD 0F DISPOSITION WHEN REMOVING FROM OPTIONS SHOWN)

1850 TOWN, CENTER PARKWAY jg; 20190 FAIRFAX COUNTY
29.METIIODOPDISPOSITION .. . 

EBURIAL 
DEURIALATSEA DONATION I 

  
    
  
  
  

 

FAISLABAD CENIETERY

 

 

 

 

 

 

 

 

  
  

 

 

 

 

34. TIME OF To the. best ofmy knowledge; death Downed II

08:55

7903 HILL PARK, #8 LORTON VIRGINIA 22079

31. PLACE OF DISPOSITION - STRHIT ADDRESS OF OR CREMATORY 31:. COUNTY 31b. STATE 31c. CODE 31d. COUNTRY
UNKNOWN PAKISTAN
32. SIGNATURE . KIN (ACTUAL SIGNATURE) 32g, IICENSEES NO . NAME mm on 
GWENDOLYN HEMMINGS 1 0502900325 SERVICES, LLC
33. NAME OF WIRECIOR LICENSEE, Vsumcm KIN 33!. STREET ADDRESS OP FUNERAL HOME IFACILITY. VSAP OR NEXT or KINUnolude urea Idd'eu. city. ante and zip code)
GWEN DOLYN HEMMIN GS

 

 

35. PART I. Enter the dine-Sea, injuries.

AM PM

 

ACTUAL

[j APPROXIMATE

PRESUMED POUND

 

IMCMEDIATE CAUSE OF DEATH

Sequentially list oonditiong.? ifany, leading
to Immediate cause. 

0f complication; that caused the death. Do not enter the mode ofdying,

CAUSE (Dilwe-or?injury that initiated evenings)

DUETO IOR AS A CONSEQUENCE OF)

multinx in dntIt) LAST

(C)

(Final diseue or condition resulting in death) (A) METASTATIC RENAL CELL CARCINOMA


such as cardiac or lupintory mt, Shock, or hurt failum

INTERVAL BETWEEN
ONSET AND DEATH

  
   
 
  
   

 

  
 
   

 

 

 

DUE To (OR As A CONSEQUENCE OF)

(D)

 

 

 

PART II. Other signi?cant conditions contributing to deulh but not resulting in the underlying cause given in Pan I.

36. WAS THE MEDICAL BXAWNER CONT ACT 

36; 

 

.DYES

i 133. IF FEMALE:

END

 

DYBS END

EYES

35b. WERE FINDINGS AVAILABIE TO COMPLETE CAUSE OF 

DNO

 

EYES END

37. DID TOBACCO USE TO 
POSSIBLY UNKNOWN

 

PREGNANT ATTIME OP DEATH

NOT PREGNANT PAST YEAR

39. IF MERNAIA TO WHAT EXTENT IT CONTRIBUTED TO CAUSE OF DEATH7

UNKNOWN IF PREGNANT WITHIN THE PAST YEAR
NOT PREGNANT, BUT PREGNANT WITHIN 43 DAYS TO 1 YEAR BEFORE DEATH

NOT PREGNANT, BUT PREGNANT WITHIN ?2 DAYS OF DEATH
DNOT APPLICABLE if decedent's is 0-5 or 75 yam)

  
  

 

DPRIMARY

CONTRIBUTING

40. WAS THIS A MILITARY 

EYES

ENG

 

NATURAL



 

41. DATE OF INJURY

42. TIME CW INJURY

ITEMS 41 T0 47 IN THIS SECTION SHOULD ONLY BE COMPLETED FOR MI

ACCIDENT



40:11? MUTARYDEATH, SELECT MANNER OF DEATH

SUICIDE

El

HOMICIDB

UNDBTERMINED

1:1 I: 1


 
 

PENDING

 

 

 

AM. [3 PM

 

43. INJURY AT 

EYES 

UNKNOWN

 

44. PLACE OF INJURY (home, factory, "not, of?ce, bids.

etc.)

 

45. LOCATION OFJNJURY-STREET ADDRESS nous: ANDDR APT. non ROUTE NO.)

 

 

45: CITY COUNTY

450. STATE

I 450. ZIP CODE

I dd. COUNTRY

 

 

  

 

    
  

   

 

 

    
       
  

  
 
 

 
   
      
        
     

    
   
    
      
   
       
  

 

April 4, 2017.

Common Wealth of Virginia

Certificate of Death

Division of Vital Record

P. O. BOX 1000, Richmond, VA, 23218.
2001 Maywill Street, Richmond, VA, 23230.
Tel: 1-877-572?6333, Fax: 1-800?244-2515

RE: Request to correct Marital Status in Death Certificate from Divorced to
?Married" Death Certificate 0858032, State File 17-003928, dated



 

l, Mrs. Samina Ashraf Gilani, Female, a US Citizen, DOB: Jan 6, 1969, SSN: 694?14?
0114, wife of US Citizen husband Muhammad Ashraf Shah (deceased on Jan 16,
2017 at Reston Hospital Center, Reston, VA), Male, DOB: May 20, 1952, SSN:
228?79-1735, state that the Common Wealth of Virginia, Division of Vital Record,
Certificate of Death, No. 0858032 is incorrectly reporting as ?Divorced? under
Marital Status of my husband. Please correct the Marital Status to ?Married? in
the Vital Records/ Certificate of Death and issue me a correct new Death
Certificate/ Vital Records, indicating Marital status as ?Married?.

Attached, please find original Death Certificate, State issued lD, Marriage
certificate, Tax Return.

Sincerely,

Samina Ashraf Gilani
6834 Kenyon Drive, Alexandria, VA, 22307