STATE FILE NO.:  97-110262
 1.  DECEDENT'S NAME:  Roy E. Pancake
 2.  SEX:  Male
 3.  DATE OF DEATH:  September 20, 1997
 4.  SOCIAL SECURITY NUMBER:  322-07-8127
 5a. AGE-Last Birthday:  79
 6.  DATE OF BIRTH:  May 26, 1918
 7.  BIRTHPLACE:  Branchland, West Virginia
 8.  WAS DECEDENT EVER IN US ARMED FORCES?:  No
 9a. PLACE OF DEATH:  Nursing Home
 9b. INSIDE CITY LIMITS?:  No
 9c. FACILITY NAME:  Mariner Health Care at Conway Lakes
 9d. CITY, TOWN, OR LOCATION OF DEATH:  Orlando
 9e. COUNTY OF DEATH:  Orange
10a. DECEDENT'S USUAL OCCUPATION:  Real Estate Agent
10b. KIND OF BUSINESS/INDUSTRY:  Real Estate Sales
11.  MARITAL STATUS:  Married
12.  SURVIVING SPOUSE (If wife, give maiden name):  Virginia E. Dowdy
13a. RESIDENCE - STATE:  Florida
13b. COUNTY:  Orange
13c. CITY, TOWN, OR LOCATION:  Orlando
13d. STREET AND NUMBER:  14409 Hertha Avenue
13e. INSIDE CITY LIMITS:  No
13f. ZIPCODE:  32826
14.  WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN?  No
15.  RACE:  White
16.  DECEDENT'S EDUCATION (Specify only highest grade completed):  7
17.  FATHER'S NAME:  Isac C. Pancake
18.  MOTHER'S NAME:  Lillie B. Johnson
19a. INFORMANT'S NAME:  Virginia E. Pancake
19b. MAILING ADDRESS:  14409 Hertha Avenue, Orlando, Florida 32826
20a. METHOD OF DISPOSITION:  Burial
20b. PLACE OF DISPOSITION:  Chapel Hill Cemetery
20c. LOCATION:  Orlando, Florida
21a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH:  [unreadable]
21b. LICENSE NUMBER:  1749
21c. NAME AND ADDRESS OF FACILITY:  BALDWIN-FAIRCHILD FUNERAL HOME
                                    7520 Aloma Ave.,
                                    Winter Park, FLA 32792
25c. DATE REGISTERED:  SEP 24 1997