State File No.:  030820
 1a.  DECEDENT'S NAME:  Gerald Leonard PANCAKE
 1b.  IF DECEDENT IS FEMALE, ENTER MAIDEN LAST NAME:
 2.   SEX:  Male
 3.   DATE OF DEATH:  FOUND: JUL 08, 1997
 4.   RACE:  White
 5.   ORIGIN OF DECEDENT:  American
 6.   DATE OF BIRTH:  OCT 18, 1933
 7a.  AGE-Last Birthday (Years):  63
 8a.  COUNTY OF DEATH:  Laurens
 8b.  CITY, TOWN or LOCATION OF DEATH:  Dublin
 9a.  HOSPITAL OR OTHER INSTITUTION NAME (If not in either, give street and No.):
      100 Parker Dairy Road
10a.  STATE AND COUNTY OF BIRTH:  GA - Washington
10b.  CITIZEN OF WHAT COUNTRY?  USA
11.   MARRIED, NEVER MARRIED, WIDOWED, DIVORCED:  Divorced
12.   SPOUSE:  [blank]
13.   WAS DECEDENT EVER IN U.S. ARMED FORCES:  YES
14.   SOCIAL SECURITY NUMBER:  254-46-1793
15a.  USUAL OCCUPATION:  Disabled
15b.  KIND OF INDUSTRY OR BUSINESS:  Disabled
RESIDENCE
16a.  STATE:  Georgia
16b.  COUNTY:  Laurens
16c.  CITY, TOWN or LOCATION:  Dublin
16d.  STREET AND NUMBER:  100 Parker Dairy Road
16e.  INSIDE CITY LIMITS?  NO
17.   FATHER'S NAME:  Harry F Pancake
18.   MOTHER'S MAIDEN NAME:  Annie L Horton
19a.  INFORMANT'S NAME:  Kathy Pancake Mercer
19b.  MAILING ADDRESS:  [private]
19c.  RELATIONSHIP:  Daughter
20a.  BURIAL, CREMATION, REMOVAL:  Cremation*
20b.  DISPOSITION DATE:  JUL 10, 1997
20c.  CEMETERY OR CREMATORY NAME:  Central Georgia Crematory
20d.  LOCATION (City or Town, State, Zip, County:  Gray, Georgia, 31029, Jones
FUNERAL DIRECTOR
21a.  (Signature):  [illegible]
21b.  FUN. DIR. LICENSE NO.:  4013
21c.  NAME AND ADDRESS OF FACILITY:  Bridges Funeral Home and Crematory
                                     Post Office Box 783
                                     Gray, Georgia 31032-0783
21d.  ST. LICENSE NO.:  1193
32a.  REGISTRAR:  Mable Harden
32b.  DATE RECEIVED BY REGISTRAR:  JULY 24, 1997

Added July 9, 2005