STATE FILE NO.:  91-006279
 1.  DECEDENT'S NAME:  Wendell R. Pancake
 2.  SEX:  Male
 3.  DATE OF DEATH:  January 21, 1991
 4.  SOCIAL SECURITY NUMBER:  295-34-5345
 5a. AGE-Last Birthday:  74
 6.  DATE OF BIRTH:  June 8, 1916
 7.  BIRTHPLACE:  Ross County, Ohio
 8.  WAS DECEDENT EVER IN US ARMED FORCES?:  yes
 9a. PLACE OF DEATH:  Hospital, ER/Outpatient
 9b. INSIDE CITY LIMITS?:  yes
 9c. FACILITY NAME:  Waterman Medical Center
 9d. CITY, TOWN, OR LOCATION OF DEATH:  Eustis
 9e. COUNTY OF DEATH:  Lake
10a. DECEDENT'S USUAL OCCUPATION:  farmer
10b. KIND OF BUSINESS/INDUSTRY:  agriculture
11.  MARITAL STATUS:  married
12.  SURVIVING SPOUSE (If wife, give maiden name):  Lillian Goodall
13a. RESIDENCE - STATE:  Ohio
13b. COUNTY:  Ross
13c. CITY, TOWN, OR LOCATION:  Frankfort
13d. STREET AND NUMBER:  1005 Frankfort Clarksburg Pike
13e. INSIDE CITY LIMITS:  no
13f. ZIPCODE:  45628
14.  WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN?  no
15.  RACE:  white
16.  DECEDENT'S EDUCATION (Specify only highest grade completed):  College, 1 [year]
17.  FATHER'S NAME:  Forrest Pancake
18.  MOTHER'S NAME:  Phoebe Lucas
19a. INFORMANT'S NAME:  Mrs. Lillian Pancake
19b. MAILING ADDRESS:  1005 Frankfort Clarksburg Pike-Frankfort, Ohio 45628
20a. METHOD OF DISPOSITION:  Removal from State
20b. PLACE OF DISPOSITION:  Greenlawn Cemetery
20c. LOCATION:  Frankfort, Ohio
21a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH:  Arthur P. Hilbish
21b. LICENSE NUMBER:  1629
21c. NAME AND ADDRESS OF FACILITY:  Hamlin & Hilbish Funeral Directors
                                    326 E. Orange Avenue-Eustis, FL. 32726
25c. DATE REGISTERED:  Jan. 22, 1991