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BUREAU of VITAL STATISTICS
CERTIFICATION OF DEATH
STATE FILE NUMBER: 2014045929
DECEDENT INFORMATION
NAME: ADONIS JESUS PENA
DATE ISSUED: April 23, 2014
STATE FILE DATE: April 1, 2014
DATE OF DEATH: March 30, 2014 SEX: MALE AGE: 021 YEARS
DATE OF BIRTH: June 10, 1992 SSN:
BIRTHPLACE: QUEENS, NEW YORK, UNITED STATES
PLACE WHERE DEATH OCCURRED: EMERGENCY ROOM/OUTPATIENT
FACILITY NAME OR STREET ADDRESS: AVENTURA HOSPITAL AND MEDICAL CENTER
LOCATION OF DEATH: AVENTURA, MIAMI-DADE COUNTY, 33180
SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION
MARITAL STATUS: NEVER -MARRIED
SPOUSE (IF FEMALE, MAIDEN NAME): NONE
RESIDENCE: 18831 NE 3RD COURT APT NO. 511, MIAMI GARDENS, FLORIDA 33169, UNITED STATES
COUNTY: MIAMI-DADE
OCCUPATION, INDUSTRY: AUTO MECHANIC, SELF EMPLOYED
RACE: X White _Black or African American Asian Indian _Chinese _Filipino _Native Hawaiian
_American Indian or Alaskan Native --Tribe: _Japanese _Korean _Vietnamese
_Guamian or Chamorro _Samoan _Other Pacific Is!:
_Other Asian: _Other: _Unknown
HISPANIC OR HAITIAN ORIGIN? YES, UNKNOWN
EDUCATION: HIGH SCHOOL GRADUATE OR GED COMPLETED EVER IN U.S. ARMED FORCES?NO
PARENTS AND INFORMANT INFORMATION
FATHER: DIOMIS ESCOTO
MOTHER: ANNA DUARTE
INFORMANT: DIOMIS ESCOTO
RELATIONSHIP TO DECEDENT: FATHER
INFORMANT'S ADDRESS: 18831 NE 3RD COURT APT NO. 511, MIAMI GARDENS, FLORIDA 33169, UNITED STATES
PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION
PLACE OF DISPOSITION: HALLANDALE BEACH CEMETERY
HALLANDALE, FLORIDA
METHOD OF DISPOSITION: BURIAL
FUNERAL DIRECTOR/LICENSE NUMBER: ROSALIND A. PINDER, F043106
FUNERAL FACILITY: ERIC L WILSON FUNERAL & CREMATION SERVICES PA F065077
4631 W HALLANDALE BEACH BLVD, HOLLYWOOD, FLORIDA 33023
CERTIFIER INFORMATION
TYPE OF CERTIFIER: ASSOCIATE MEDICAL EXAMINER MEDICAL EXAMINER CASE NUMBER: 141100896
TIME OF DEATH (24 hr): 0131
CERTIFIER'S NAME: EMMA OY HIR LEW
CERTIFIER'S LICENSE NUMBER: ME62926
NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT ENTERED
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THE ABOVE SIGNATURE CERTIFIES TRAHHIS IS A TR1)Et4`ro GVRRL§.t{4E)PY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE.
THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH WATERMARKS OF THE GREAT
WARNING: SEAL OF THE STATE OF FLORIDA. DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATER-
MARKS. THE DOCUMENT FADE CONTAINS A MULTICOLORED BACKGROUND. GOLD EMBOSSED SEAL. AND
THERA OCHHOMIC FL THE BACK CONTAINS SPECIAL LINES WITH TEXT. THE DOCUMENT WILLMO' PRODUCE
A COLOR COPY.
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