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ANY ALTERATION OR
OIDS THIS CERTIFICATE'
Irir )II.''NT
Y
17. FATNEVES rrs I
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10e MA ,ri y 8TRE T 0201.0. MJM6ER
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STATE, F
mmereivorgi'nq
EFIEMeORY-
Ln. .,C'0 ,I11C1
LI k111 AIR
ran all`'. e
226.
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a -t hle l Hamblin
1Sb =;AEIAn0N D efDEdT
270. HOUR
690E
3 101
PT! PR Tows STATE
23e. PRONOUNCED DEAD Wan
1:35 a N
ataLV ern
BLACK
INK
`INSTRUCTIONS
SEE
HANDBOOK
VR 249
`194 „15M
LOCAL FILE NINAIER 10
1. DECEDENT- NAME... FIRS)'
4. Kim
SOCIAL 8ECU)STY KAISER
tl4217E1; seism 0 eeroutworn* O DOA
76. FACT JTY NAME'(# not. InWSnlAn, giN aartN snd, 4wnCr
Lions Park Adj ,se nt,to
8. STATE OF SRTH (2 net 21 am
USA, ne cq•I.YyJ'
Utah
O tt. WA8 DECEDENT EVER N US ARMED FO
(Speedy we or no)
Yes
17y. RECrowlen:::'zrATE
Wvo7-n ins
S•. N &DE CfTY
(80•08(1 AIR
STATE OF WYOMING
8T:
sn pd tire
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1 8Sa0Yy ya
R Lereloon Puerto
E AND ADDRESS 'OF CE
i
Jerry Glasscock* .1032
a.. siernNR
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
reeve Hew 0 Reasons. toes. r
Oa
Marri era'
129 U87*2. 000) 1710N RTkA or 922 4d+IF,drla
d Hy NIA, Won SMAW
Plant:- M0hanio
>fr TovyrJOae N
a "•2
h Stree
(8 3
PART L Enter w datums, brudes awro20.dnne IPM caused tlsade (19 w mode erdy 1
er r.WN2Nr7117021 Or'2M,I Ilium ON .1Ay 006 Cat., CO volt
IMMEDUf?E 0XUSE 19w
dWM or eardll0n
emoting le demN)
setpiwiteie7Ile Ceid0210.
:EbM, Serene le Inu edlaIo
oat* ie M:UNDSIILWIq
CAW! (0411 ov 4Siry
m INWSQYNnb
nmulunp S OWN LAST
066326.
d.
DUE TO (01 AS A CONSEQUENCE OF):
Asphyxia
DUE TO (OR AS A CONSEQUENCE OFT
.:Hanging
DUE TO (OR AS A CONSEQUENCE OF):
'MST, canes sesteCAIlT CQNDITip48- CN0*02. ...bens to dub but rnl nested lo ewes Otto In PART 1
28. MANNER OF DEATH
Neturel o
molars
awed. ['Coed nos be
7aMmAlltd':
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne' Wyoming.
DATE ISSUED:
LAST 2. SEE S DATE OF DEATH (110,: OI7, 11)
Found
Kla Mai A^ October 2,8 199R
i0. i)N(E i Se. UNDER i bb*V S. DATE OF ISSN 4A1u, DA) YO
Months Dove Haan MSuteo
0al-ghrsr' 5, 1949
TOWN; 0R LOCATION OF DEATH
Yemm re'r
CP,AUR F/NO Sr0U6@(1(
R ,X
1E.R�CE- Andnlnllan,
2048, WNS Eb.
tbmer'er°
0 LA sau
n nano
h
191 '1';:R
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
=WE FAE NUMBER
34
it COUNTY OF DEATH
Lincoln
mi 3101
2 DATE RECEIVED eY REGISTRAR (Ara;. DAY, W.)
November 2.' 1998'`
700. DESCRIBE NOW 1NK2RY OCCURRED
Lucinda McCaffrey
Deputy Stele Registrar
r AapNId
Memel Ie{WNn
oruM.uq brain,
Minutes
27. AUTOPSY Awn*MY 22. MR8 CASE :REFE O TO CORONER
yn.:w no (Wooly Ws w no)
No Yes
30a. DATE OF 00111(1 30b. TIME OF 702. WIRY AT WORK?
(Mawr, Def. yews INJURY (War 1•a ter 023
Found
Oct. 28, 1998 unknowN No Victim:.hung.self
700 PLACE OF INJURY-Al hoot Not arms. knew. 701. TI ON l tM w�.r w Ru r gad.
e1Sw hake .a2. (Spay, C ounty. Road 1.2 3 L
Park adjacent to Co. Road 12 -327 North of Kemmerer; Wvoming
from tree
Weber, ON or Town, Wt.)