<PAGE> 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).
<PAGE> 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-
<PAGE> 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-
<PAGE> 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-
<PAGE> 1
EXHIBIT 1
PROBATE DOCUMENTS
-5-
<PAGE> 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.
<PAGE> 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
<PAGE> 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.
<PAGE> 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
<PAGE> 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
<PAGE> 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
<PAGE> 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
<PAGE> 9
<TABLE>
<S> <C> <C>
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
</TABLE>
<PAGE> 10
<TABLE>
<S> <C> <C> <C> <C>
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
</TABLE>
