0000950134-95-002077.txt : 19950821 0000950134-95-002077.hdr.sgml : 19950821 ACCESSION NUMBER: 0000950134-95-002077 CONFORMED SUBMISSION TYPE: SC 13D PUBLIC DOCUMENT COUNT: 2 FILED AS OF DATE: 19950818 SROS: NYSE SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: BELO A H CORP CENTRAL INDEX KEY: 0000356080 STANDARD INDUSTRIAL CLASSIFICATION: NEWSPAPERS: PUBLISHING OR PUBLISHING & PRINTING [2711] IRS NUMBER: 750135890 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13D SEC ACT: 1934 Act SEC FILE NUMBER: 005-33100 FILM NUMBER: 95565333 BUSINESS ADDRESS: STREET 1: 400 S RECORD ST STREET 2: COMMUNICATIONS CENTER CITY: DALLAS STATE: TX ZIP: 75202 BUSINESS PHONE: 2149776600 MAIL ADDRESS: STREET 1: P O BOX 655237 CITY: DALLAS STATE: TX ZIP: 75265 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: DEALEY JOE M CENTRAL INDEX KEY: 0000903646 STANDARD INDUSTRIAL CLASSIFICATION: UNKNOWN SIC - 0000 [0000] IRS NUMBER: 457092852 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13D BUSINESS ADDRESS: STREET 1: 8333 DOUGLAS SUITE 1575 CITY: DALLAS STATE: TX ZIP: 75225 BUSINESS PHONE: 2149446606 MAIL ADDRESS: STREET 1: DEALEY, JOSEPH M SR. STREET 2: P O BOX 655237 CITY: DALLAS STATE: TX ZIP: 75265-5237 SC 13D 1 SCHEDULE 13D BE FOR JOE M. DEALEY 1 UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 SCHEDULE 13D UNDER THE SECURITIES EXCHANGE ACT OF 1934 (AMENDMENT NO. _________)* A. H. BELO CORPORATION ---------------------- (Name of Issuer) Series B Common Stock, par value $1.67 per share ------------------------------------------------ (Title of Class of Securities) 080555 20 4 ----------- (CUSIP Number) Michael J. McCarthy, Communications Center, 400 South Record Street, Dallas, Texas 75202, (214) 977-6606 -------------------------------------------------------------------------------- (Name, Address and Telephone Number of Person Authorized to Receive Notices and Communications) May 10, 1995 ------------ (Date of Event which Requires Filing of this Statement) If the filing person has previously filed a statement on Schedule 13G to report the acquisition which is the subject of this Schedule 13D, and is filing this schedule because of Rule 13d-1(b)(3) or (4), check the following box [ ]. Check the following box if a fee is being paid with the statement [X]. (A fee is not required only if the reporting person: (1) has a previous statement on file reporting beneficial ownership of more than five percent of the class of securities described in Item 1; and (2) has filed no amendment subsequent thereto reporting beneficial ownership of five percent or less of such class.) (See Rule 13d-7.) NOTE: Six copies of this statement, including all exhibits, should be filed with the Commission. See Rule 13d-1(a) for other parties to whom copies are to be sent. *The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter disclosures provided in a prior cover page. The information required on the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). 2 SCHEDULE 13D CUSIP NO. 080555 20 4 PAGE 2 OF 14 PAGES -------------------------------------------------------------------------------- 1 NAME OF REPORTING PERSON S.S. OR I.R.S. IDENTIFICATION NO. OF ABOVE PERSON ESTATE OF JOE M. DEALEY S.S. NO. ###-##-#### -------------------------------------------------------------------------------- 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) / / (b) / / -------------------------------------------------------------------------------- 3 SEC USE ONLY -------------------------------------------------------------------------------- 4 SOURCE OF FUNDS* OO -------------------------------------------------------------------------------- 5 CHECK BOX IF DISCLOSURE OF LEGAL PROCEEDINGS IS REQUIRED PURSUANT TO ITEMS 2(d) or 2(e) / / -------------------------------------------------------------------------------- 6 CITIZENSHIP OR PLACE OF ORGANIZATION TEXAS -------------------------------------------------------------------------------- 7 SOLE VOTING POWER NUMBER OF 455,982 SHARES ------------------------------------------------- 8 SHARED VOTING POWER BENEFICIALLY 0 OWNED BY ------------------------------------------------ EACH 9 SOLE DISPOSITIVE POWER REPORTING 455,982 PERSON ------------------------------------------------ 10 SHARED DISPOSITIVE POWER WITH 0 ------------------------------------------------------------------------------- 11 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 455,982 -------------------------------------------------------------------------------- 12 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (11) EXCLUDES CERTAIN SHARES* /X/ -------------------------------------------------------------------------------- 13 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (11) 9.7% -------------------------------------------------------------------------------- 14 TYPE OF REPORTING PERSON* OO -------------------------------------------------------------------------------- (1) Doris C. Dealey owns 300 shares of Series B, as to all of which shares the estate of Joe M. Dealey disclaims beneficial ownership. -2- 3 ITEM 1. SECURITY AND ISSUER This statement relates to the Series B Common Stock, $1.67 par value (the "Common Stock") of A. H. Belo Corporation (the "Company"). The address of the principal executive offices of the Company is Communications Center, 400 South Record Street, Dallas, Texas 75202. ITEM 2. IDENTITY AND BACKGROUND This statement is being filed by the Estate of Joe M. Dealey. The Estate is being probated in Dallas County, Texas. ITEM 3. SOURCE AND AMOUNT OF FUNDS OR OTHER CONSIDERATION Not applicable. ITEM 4. PURPOSE OF TRANSACTION Not applicable. ITEM 5. INTEREST IN SECURITIES OF THE ISSUER (a) The Estate of Joe M. Dealey beneficially owns an aggregate of 455,982 shares, or approximately 9.7%, of Series B Common Stock of the outstanding Series B Common Stock based on the number of shares outstanding in the most recently available filing by the Company with the Securities and Exchange Commission. The Estate disclaims beneficial ownership in the 300 shares of Series B Common Stock individually owned by Doris C. Dealey. (b) The Estate, through its executor, Doris C. Dealey, has sole voting and dispositive power over 455,982 shares of Series B Common Stock. (c) On May 11, 1995, the Estate of Joe M. Dealey distributed all of the shares of Series B Common Stock beneficially owned by the Estate to the beneficiary, Doris C. Dealey. (d) None. (e) The Estate ceased to be the beneficial owner of more than five percent of the Series B Common Stock on May 11, 1995. ITEM 6. CONTRACTS, ARRANGEMENTS, UNDERSTANDINGS OR RELATIONSHIP WITH RESPECT TO SECURITIES OF THE ISSUER. The Estate has not entered into any contracts, arrangements, understandings or relationships (legal or otherwise) with any person with respect to any securities of the Company. ITEM 7. MATERIAL TO BE FILED AS EXHIBITS Exhibit 1 - Probate documents. -3- 4 SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Date: August 17, 1995 ESTATE OF JOE M. DEALEY By: /s/ DORIS C. DEALEY ------------------------------- Doris C. Dealey, Executor -4- EX-1 2 PROBATE DOCUMENTS 1 EXHIBIT 1 PROBATE DOCUMENTS -5- 2 NO. 95-1573-P2 IN THE MATTER OF Section IN THE PROBATE COURT Section THE ESTATE OF Section NO. _________ OF Section JOSEPH MACDONALD DEALEY, Section DALLAS COUNTY, TEXAS DECEASED APPLICATION FOR PROBATE OF WILL AND ISSUANCE OF LETTERS TESTAMENTARY TO THE HONORABLE JUDGE OF SAID COURT: The undersigned Applicant files this Application for probate of the Last Will and Testament of Joseph MacDonald Dealey, Deceased ("Decedent") and issuance of Letters Testamentary. Attached to this Application is the Last Will and Testament of Decedent. INFORMATION REQUIRED BY SECTION 81, TEX. PROB. CODE: NAME AND DOMICILE OF APPLICANT: Applicant is Doris Carolyn Russell Dealey, who resides at 4332 Arcady Avenue, Dallas, Dallas County, Texas 75205. NAME AND DOMICILE OF DECEDENT: Decedent was domiciled in Dallas, Dallas County, Texas. FACT, PLACE AND DATE OF DEATH: Decedent died in Dallas, Dallas County, Texas, on April 7, 1995. DECEDENT'S BIRTH DATE AND AGE: Decedent was born July 18, 1919, and was 75 years old at the time of Decedent's death. VENUE FACTS (SECTION 6, TEX. PROB. CODE): This Court has jurisdiction and venue. Decedent resided in Dallas County, Texas, owned property situated in Dallas County, Texas, and was physically located in Dallas County, Texas at the time of Decedent's death. PROPERTY: Decedent owned real and personal property at the time of Decedent's death of a probable value of One Hundred Thousand Dollars ($100,000.00) or more. LAST WILL AND TESTAMENT AND DATE THEREOF: Attached to this Application is Decedent's Last Will and Testament which is dated December 1, 1994. More than four years have not elapsed from the date of Decedent's death and this Application. 3 EXECUTRIX NAMED IN LAST WILL AND TESTAMENT: Applicant is named as Independent Executrix in Decedent's Last Will and Testament, to serve without bond. NAME AND RESIDENCE OF EACH WITNESS TO LAST WILL AND TESTAMENT: William Calvin Smellage 23 Rough Creek Granbury, Texas 76048 Betty Pool Martin 2808 MaverickDallas, Texas 75228 AFTER-BORN CHILDREN: No child or children was/were born to or adopted by Decedent after the making of Decedent's Last Will and Testament. QUALIFICATION OF INDEPENDENT EXECUTRIX: Applicant is not disqualified by law from serving as Independent Executrix of Decedent's Estate or from accepting Letters Testamentary. DIVORCE: Decedent was never divorced. TAX IDENTIFICATION NUMBERS: Decedent's social security number is ###-##-####. Applicant's social security number is ###-##-####. GOVERNMENT AGENCY OR CHARITY AS BENEFICIARY: Decedent's Last Will and Testament does not name the State of Texas, a government agency or charitable organization as devisee. LAST WILL AND TESTAMENT IS SELF-PROVED: Decedent's Last Will and Testament is self-proved and meets the requirements for a selfproved will required by Section 59, Tex. Prob. Code. REQUEST FOR ORDER AND LETTERS TESTAMENTARY: Applicant requests that this Court, upon notice and hearing as required by law, admit Decedent's Last Will and Testament to probate and record and that this Court authorize the issuance of Letters Testamentary to Applicant upon Applicant's qualification. Date: April 24, 1995 Applicant: /s/ Doris Carolyn Russell Dealey --------------------------------------------- Doris Carolyn Russell Dealey Attorney for Applicant: /s/ Wm. E. Livingstone, III, Esq. --------------------------------------------- Wm. E. Livingstone, III, Esq. State Bar No. 12441000 8333 Douglas Avenue, Suite 1510 Dallas, Texas 75225 214/739-2292, Telephone 214/739-2291 Telefax 4 NO. 95-1573-P2 IN RE: ESTATE OF Section IN THE PROBATE COURT Section JOSEPH MACDONALD DEALEY, Section NO. 2 OF Section DECEASED Section DALLAS COUNTY, TEXAS ORDER PROBATING WILL AND AUTHORIZING ISSUANCE OF LETTERS TESTAMENTARY On this day came to be heard the application to probate that certain instrument in writing dated December 1, 1994, which was filed with the Application for Probate of Will and Issuance of Letters Testamentary and which is purported and alleged to be the Last Will and Testament of Joseph MacDonald Dealey, Deceased. Due proof was taken in the manner required by law, and it appears to the satisfaction of the Court that this Court has jurisdiction and venue over the Decedent's Estate, these proceedings and the subject matter. Having considered the evidence, the Court makes the following findings of fact: 1. Notices of Applicant's filing of the Application for Probate of Will and Issuance of Letters Testamentary have been issued and posted in the manner and for the length of time required by law, and no one has appeared to contest same. 2. The Decedent is deceased. The Decedent died on April 7, 1995, in Dallas County, Texas, at the age of 75 years. 3. The Decedent's residence and principal estate is, and was at the time of his death, situated in Dallas County, Texas. 4. Four years have not elapsed since the Decedent's death and prior to the application to probate the Decedent's Will. 5. At the time the Will was executed, the Decedent was of legal age and sound mind, and the Will was executed with the formalities and solemnities and under the circumstances required by law to make the Will a valid, self- proved will. 6. The Decedent's Will was not revoked prior to his death. 7. Doris Carolyn Russell Dealey is named in the Will as Executrix of the Decedent's Estate without bond and is not disqualified by law from accepting Letters Testamentary. 8. No child or children was/were; born to or adopted by the Decedent after the execution of the Will. 9. The Decedent was not divorced prior to the date of the Will. 5 10. No contest or objection to the admission of the Will to probate has been filed. THEREFORE, IT IS THE ORDER OF THIS COURT AS FOLLOWS: 1. The Will filed with the Application for Probate of Will and Issuance of Letters Testamentary is hereby proven, established and admitted to probate and record as the Last Will and Testament of the Decedent. 2. Doris Carolyn Russell Dealey is entitled to receive Letters Testamentary, and the same are hereby granted to Doris Carolyn Russell Dealey without bond, upon the taking of the oath as required by law, and the Clerk of this Court shall issue Letters Testamentary in accordance with this Order when Doris Carolyn Russell Dealey shall have qualified according to law. 3. No necessity exists for the appointment of appraisers of the ,assets of the Decedent's Estate. 4. The proceedings herein shall he recorded by the Clerk in the Minutes of the Court. EXECUTED this 10 day of May, 1995. /s/ Judge Robert E. Price ------------------------------ Judge Robert E. Price APPROVED: /s/ Wm. E. Linvingstone, III --------------------------------- Wm. E. Livingstone, III, Esq. State Bar No. 12441000 8333 Douglas Avenue, Suite 1510 Dallas, Texas 75225 214/739-2292 Telephone 214/739-2291 Telefax 6 THE STATE OF TEXAS COUNTY OF DALLAS KNOW ALL MEN BY THESE PRESENTS THAT I, Joseph MacDonald Dealey of Dallas, Dallas County, Texas being of sound and disposing mind, memory and understanding, and above the age of twenty-one years, in view of the uncertainty of life and for the purpose of making the best disposition of my worldly affairs, do hereby make and publish. this, my Last Will and Testament, hereby revoking all former wills, if any, by me heretofore made. I. I direct that all of my just debts and all my funeral expenses shall be paid as soon after my death as may be convenient, and that all valid estate, transfer and inheritance taxes, whether imposed by the government of the United States or by the government of any state or of any foreign country on or in respect to any of my property or any devise or bequest herein contained, shall be treated in all respects as if they were debts for which I was liable at the time of my death and shall be paid out of my general estate. II. Subject to the payment of my said debts and the expense incident to the probating of this will, I give, devise and bequeath all of my property, real, personal and mixed, of every kind and character, to my beloved wife, Doris Carolyn Russell Dealey, provided she survives me by thirty (30) days. Should Doris Carolyn Russell Dealey not survive me by thirty (30) days then to my children, Joseph MacDonald Dealey, Jr., Pamela Carolyn Dealey Campbell, Russell Edward Dealey, and Frances Patricia Dealey Scarbrough, share and share alike. Should any one of my children be deceased at the time of my death, the deceased child's share of my estate shall pass to the living, blood heirs of his or her children per stirpes. I hereby nominate, constitute and appoint my beloved wife, Doris Carolyn Russell Dealey, as Executrix of my estate and direct that no bond or other security be required of her as Executrix. I direct that no other action shall be had in the County Court or other Court exercising probate jurisdiction in relation to the administration and settling of my estate than the probating and recording of this, my Last Will and Testament, and the return of an inventory appraisement and list of claims of my estate. In the event that my said wife shall for any reason fail or cease to serve as Independent Executrix, then I designate my beloved children; Joseph MacDonald Dealey, Jr., Pamela Carolyn Dealey Campbell, Russell Edward Dealey, and Frances Patricia Dealey Scarbrough, as my said joint Independent Executors and Executrixs or the survivors. I authorize and empower my said Executrix to sell, dispose of, deliver and convey any portion of my estate, real, personal, or mixed, at public or private sale for any price on any terms and in any manner that may seem to her best for the purpose of paying any of my debts or in making and delivering said bequests. IN TESTIMONY WHEREOF, I JOSEPH MACDONALD DEALEY, have subscribed my name to this, my Last Will and Testament, and in addition at my request, William Calvin Smellage and Betty Pool Martin, both of Dallas County, Texas, and both credible witnesses above the ages of fourteen (14) years in my presence and in the presence of each other, have hereunto set their names as witnesses in Dallas, Dallas County, Texas, this 1st day of December 1994. /s/ JOSEPH MACDONALD DEALEY ------------------------------------- JOSEPH MACDONALD DEALEY, TESTATOR JOSEPH MACDONALD DEALEY signed his name to the foregoing instrument at Dallas, Texas, the 1st day of December , 1994 in the presence of each of us; and to us declared such instrument to be his Last Will and Testament, and now, at his request, in his presence and in the presence of each other, we subscribed the same as witnesses. /s/ William Calvin Smellage ---------------------------------- William Calvin Smellage 23 Rough Creek, Granbury, Texas 76048 ---------------------------------- --------------------------------------- Name /s/ Betty Pool Martin ---------------------------------- Betty Pool Martin 2808 Maverick, Dallas, Texas 75228 ---------------------------------- --------------------------------------- Name Address STATE OF TEXAS Page 1 of 2 7 COUNTY OF DALLAS BEFORE ME, the undersigned authority, on this day personally appeared JOSEPH MACDONALD DEALEY, William Calvin Smellage and Betty Pool Martin, known to me to be the Testator and the witnesses, respectively, whose names are subscribed to the annexed or foregoing instrument in their respective capacities; and all of said persons being by me duly sworn, the said JOSEPH MACDONALD DEALEY, Testator, declared to me and to the said witnesses in my presence that said instrument is his Last Will and Testament, and that he had willingly made and executed it as his free act and deed, for the purposes therein expressed; and the said witnesses, each on his oath, stated to me in the presence and hearing of the said Testator that the said Testator had declared to them that said instrument is his Last Will and Testament and that he executed the same as such and wanted each of them to sign it as a witness; and upon their oaths each witness stated further that they did sign the same as witnesses in the presence of the said Testator and at his request, that he was at that time nineteen (19) years of age or over and was of sound mind; and that each of said witnesses was then at least fourteen (14) years of age. /s/ JOSEPH MACDONALD DEALEY ------------------------------------- JOSEPH MACDONALD DEALEY /s/ William Calvin Smellage ------------------------------------- Witness /s/ Betty Pool Martin ------------------------------------- Witness SUBSCRIBED AND ACKNOWLEDGED before me by the said JOSEPH MACDONALD DEALEY, Testator, and subscribed and sworn to before me the said William Calvin Smellage and Betty Pool Martin, witnesses, this the 1 day of December ________ 1994. /s/ Teresa M. Fischer ---------------------------------- Notary Public in and for Dallas County, Texas Page 2 of 2 8 LETTERS TESTAMENTARY STATE OF TEXAS Section IN THE PROBATE COURT NO. 2 Section COUNTY OF DALLAS Section DALLAS COUNTY, TEXAS CAUSE NO. 95-1573-P2 I, Earl Bullock, County Clerk and Clerk of the County and Probate Courts, in and for said County, do hereby certify that on the 10th day of May, 1995, DORIS CAROLYN RUSSELL DEALEY was appointed Independent Executor, without bond, of the Will and Estate of JOSEPH MACDONALD DEALEY, Deceased, and that said appointee is fully and legally authorized and empowered to act as the Independent Executor, without bond, of the Will and of the above named estate, having qualified by filing the oath on the 10th day of May, 1995. I further certify that said appointment is still in full force and effect. Witness my hand and Official Seal of office, this 10th day of May, 1995. EARL BULLOCK, COUNTY CLERK DALLAS COUNTY, TEXAS BY: /s/ Tina Williams Deputy TINA WILLIAMS 9 STATE OF TEXAS CERTIFICATE OF DEATH STATE FILE NUMBER 1. NAME OF DECEASED (a) FIRST (b) MIDDLE (c) LAST (d) MAIDEN 2. SEX 3. DATE OF DEATH Joseph MacDonald Dealey Male April 7, 1995 4. DATE OF BIRTH 5. AGE IF UNDER 1 YR. IF UNDER 1 DAY 6. BIRTH PLACE 7. SOCIAL SECURITY NO. (IN YEARS) MO DAYS HOURS MIN (CITY & STATE OR FOREIGN COUNTRY) July 18, 1919 75 Dallas, Texas ###-##-#### 8. RACE 9a. WAS THE DECEDENT 9b. IF YES, SPECIFY (MEXICAN, 10. WAS DECEDENT EVER IN 11. EDUCATION (SPECIFY HIGHEST GRADE OF HISPANIC ORIGIN? CUBAN, PUERTO RICAN, ETC.) U.S. ARMED FORCES?COMPLETED, ELEM. OR SECONDARY (0-12) COLLEGE White [ ] YES [x] NO [x] YES [ ] NO (13-16, 17+) 16 years 12. MARITAL STATUS 13. SURVIVING SPOUSE 14a. DECEDENT'S USUAL OCCUPATION 14b. KIND OF BUSINESS OR INDUSTRY (IF WIFE, GIVE MAIDEN NAME) [x] MARRIED [ ] NEVER MARRIED Doris Carolyn Russell Former Ch. of Board A.H. Belo Corporation [ ] WIDOWED [ ] DIVORCED 15a. RESIDENCE STREET ADDRESS 15b. CITY OR TOWN 4332 Arcady Highland Park 15c. COUNTY 15d. STATE 15e. ZIP CODE 15f. INSIDE CITY LIMITS Dallas Texas 75205 [x] YES [ ] NO 16. FATHER'S NAME 17. MOTHER'S MAIDEN NAME Edward Musgrove Dealey Clara MacDonald 18. PLACE OF DEATH (CHECK ONLY ONE) HOSPITAL: [ ] INPATIENT [ ] ER/OUTPATIENT [ ] DOA OTHER: [ ] NURSING HOME: [x] RESIDENCE [ ] OTHER (SPECIFY) 19. COUNTY OF DEATH 20. CITY OR TOWN (IF OUTSIDE CITY 21. NAME OF HOSPITAL OR INSTITUTION LIMITS, GIVE PRECINCT NO.) (If not in institution, show street address) Dallas Highland Park 4332 Arcady 22. INFORMANT-SIGNATURE & RELATIONSHIP 23. MAILING ADDRESS OF INFORMANT JOE M. DEALEY, JR., SON 4332 Fairfax, Dallas, TX 75205 24. METHOD OF DISPOSITION 25. PLACE OF DISPOSITION (NAME OF 29. NAME & ADDRESS OF FUNERAL HOME CEMETERY, CREMATORY OR OTHER PLACE) Sparkman/Hillcrest [x] BURIAL Grove Hill Cemetery 7405 West Northwest Highway [ ] CREMATION Dallas, Texas [ ] REMOVAL FROM STAT 26. LOCATION (CITY, STATE) 27. DATE OF DISPOSITION [ ] DONATION Dallas, Texas 75225 04/11/1995 [ ] OTHER (SPECIFY) 28. SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH /s/ David Z. Sparkman #7412 30. CERTIFIER [x] CERTIFYING PHYSICIAN TO THE BEST OF MY KNOWLEDGE DEATH OCCURRED AT THE TIME, DATE, AND PLACE, AND DUE TO THE CAUSE(S) AND MANNER AS STATED. [ ] MEDICAL EXAMINER ON THE BASIS OF EXAMINATION AND/OR INVESTIGATION, IN MY OPINION, DEATH OCCURRED AT THE TIME, DATE, PLACE, AND DUE TO THE [ ] JUSTICE OF THE PEACE CAUSE(S) AND MANNER AS STATED. 31. SIGNATURE & TITLE OF CERTIFIER 32. DATE SIGNED 33. TIME OF DEATH /s/ KJMcIntyre Ms MO DAY YEAR 4 10 95 4:45 P.M. 34. PRINTED NAME & ADDRESS OF CERTIFIER Kristi J McIntyre Ms 8230 Walnut Hill, Dallas, Texas 75231 35. PART 1 ENTER THE DISEASES, INJURIES OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING APPROXIMATE SUCH AS CARDIAC OR RESPIRATORY ARREST, SHOCK, OR HEART FAILURE. LIST ONLY ONE CAUSE ON EACH LINE. INTERVAL BETWEEN ONSET AND DEATH IMMEDIATE CAUSE (FINAL DISEASE OR CONDITION RESULTING IN DEATH) a. Pneumonia 4 days ------------------------------------------------------------------- DUE TO (OR AS A LIKELY CONSEQUENCE OF): b. Metastatic Nonsmall Cell Carcenoma of lung with brain involvement ------------------------------------------------------------------- SEQUENTIALLY LIST CONDITIONS, IF ANY, DUE TO (OR AS A LIKELY CONSEQUENCE OF): LEADING TO IMMEDIATE CAUSE. ENTER UNDERLYING CAUSE (DISEASE c. OR INJURY THAT INITIATED EVENTS ------------------------------------------------------------------- RESULTING IN DEATH) LAST DUE TO (OR AS A LIKELY CONSEQUENCE OF): d. ------------------------------------------------------------------- PART 2 OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 36a. AUTOPSY? 36b. AUTOPSY FINDINGS AVAILABLE IN THE UNDERLYING CAUSE GIVEN IN PART 1 (i.e., substance abuse, PRIOR TO COMPLETION OF CAUSE diabetes, smoking, etc.) OF DEATH? [ ] YES [x] NO [ ] YES [x] NO 37. DID TOBACCO USE CONTRIBUTE TO DEATH 38. DID ALCOHOL USE CONTRIBUTE TO DEATH 39. WAS DECEDENT PREGNANT [x] YES [ ] PROBABLY [ ] YES [ ] PROBABLY AT TIME OF DEATH [ ] YES [x] NO [ ] UNK [ ] NO [ ] UNKNOWN [x] NO [ ] UNKNOWN WITHIN LAST 12 MO [ ] YES [x] NO [ ] UNK
10 40. MANNER OF DEATH 41a. DATE OF INJURY 41b. TIME OF INJURY 41c. INJURY AT WORK 41d. PLACE OF INJURY-AT HOME, FARM, STREET, FACTORY, OFFICE, ETC. (SPECIFY) M. [ ] YES [x] NO [x] NATURAL 41e. LOCATION (STREET AND NUMBER, CITY OR TOWN, STATE) [ ] ACCIDENT [ ] SUICIDE 41f. DESCRIBE HOW INJURY OCCURRED [ ] HOMICIDE [ ] PENDING INVESTIGATION [ ] COULD NOT BE DETERMINED 42a. REGISTRATION NO. 42b. DATE RECEIVED BY LOCAL REGISTRAR 42c. SIGNATURE OF LOCAL REGISTRAR 001-010-95 04-13-95 /s/ EARL BULLOCK