Alexis Arquette, the transgender actress and sibling of David, Rosanna, Richmond and Patricia, died of a heart attack that was related to having HIV for 29 years, The Associated Press reports.

Arquette died September 11, 2016, in Los Angeles, but the cause of death had not been confirmed until the death certificate was released September 20.

According to the death certificate, the immediate cause of death was cardiac arrest. Underlying causes were having cardiomyopathy—a disease of the heart muscle—for three years and HIV for 29 years.

Arquette played a transgender sex worker in Last Exit to Brooklyn and a Boy George impersonator in The Wedding Singer. Her transition from male to female was the subject of the 2007 documentary Alexis Arquette: She’s My Brother. She also appeared in Wigstock: The Movie and Pulp Fiction and was known as a transgender activist and outspoken celebrity.

The death certificate listed her full name as Robert Alexis Arquette and her sex as male. The proper choice of pronoun to use in referring to Arquette has been a topic of discussion since she died. Even her brother, Richmond, addressed the issue in a Facebook post:

I’ve read that some people are offended by my use of the male pronoun in referring to Alexis in a Facebook post I made shortly after her passing, a post that was picked up and quoted by various news outlets.… Alexis was known for some of her life as a male, he was known for some of his life as a woman, and as transgender, but all of these words are inadequate. If one must ascribe Alexis with a gender, know this: Alexis was Transcended Gender. The words of the English language are lacking. As such, it is irrelevant whether you use he or she, her or him, his or hers, sister or brother, you cannot get close to the grand and wonderful spirit that we knew as Alexis Arquette.… those who take offense at my use of the male pronoun were quite simply not privy to the many conversations we had near the end of Alexis’ life.

Earlier this year, Arquette joined drag star Jackie Beat and director Barry Shils to discuss drag and 1995’s Wigstock: The Movie for a panel discussion at RuPaul’s DragCon. The footage was released “in loving memory” of Arquette a day after her death.