Epstein Secrets

care in last 33 days 72 Yes No U Papitil in-pabent HeepiW ED/ outpatient U •losp COA C Other. specify: J J Nursing hone/long teem care Hospice rickey Decedent's residence DAM AND HOUR Of MAIM: 08/10/2019 7:36 AM Unk INJURY: Date Time: AM PM AT WORK J YES U NO TYPE OF PLACE:Irk

0 Quinn, Thomas M. & Sons Funeral Home 0 Riverside Memorial Chapel O Riverside Memorial Chapel 0 Riverside Memorial Chapel 0 Riverside • Nassau North Chapels 0 Schwartz Brothers -Jeflor Memorial Chapel 0 Univeral Funeral Chapel 0 Virginia Funeral Chapel 0 Waterbury & Kelly Funeral Home O Waterbury & K

r: O Recent hospitalizations or travel: if yes, where and when: O Dentist name/address): O Tattoos or scars (e.g., old surgery), describe: 0 Any Hospice care in last 30 days? If so, where: High blood pressure Heart problems Diabetes Seizures Lung problems Tuberculosis Tobacco use Brain infecti

uinn, Thomas N. & Sons Funeral Henke O Riverside Memorial Chapel O Riverside Memorial Chapel O Riverside Memorial Chapel C O Riverside • Hasse. North Chapels O Schwartz Brothers - !eller Memorial Chapel O unlveral Funeral Chapel O Virginia Funeral Chapel CO Welerbury & Kelly Funeral Home O Walerbury 8

last 93 days Yes ijb• No u NO U. 0 Hospital In-patient Hospital ED/outpatient Hoop DOA Other specify: u U U Nursing harnMong term care Hospice facity Decedents resktence DATE AND HOUR OF DEATH: 08/10/2019 7:36 AM u Unk INJURY: Date Time: AM PM AT WORK U YES U NO TYPE OF PIACE

ty O Quinn, Thomas M. & Sons Furnwa/ Home Riverside Memorial Chapel O Riverside Memorial Chapel O Riverside Memorial Chapel O Riverside - Nassau North Chapels O Schwartz Brothers -Jetkr Memorial Chapel 0 Universe Funeral Chapel O Virginia Funeral Chapel O Waterbury & Kelly Funeral Home O Waterbury & Ke