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Omer ISpeolY) 9i41 1 911s4 „'#3 death reposed 10 M.E.? tll 1109 ad r repgrtw. i e Case No DAY 30 W. Phillips, Kaysville, 3e. DATE OF DEATH )MO. Day. Yr.) June 29 1998 Bb. NAME OF HOSPITAL NURSING HOME give street address of locasool 1741 W. Phillips 9. SURVIVING SPOUSE NI wde.gyn maabn name) E. Melvin Wilde ,ED 09 TS USUAL OCCUPATION (Olve kind of work done ..4udhq"moat of working life. Do NOT use reuredl 15. RACE Black. While. Am. Indian 1Tribe may Oa entered). Japanese. eta. )Spar its MAIDEN NAME OF MOTHER (First. Middle. Last) Maude Graves Utah 84037 16. EDUCATION ISpecry only highest vac competed) Elementary or Secondary (0.121 College (11I,¢ or 17 Trifr ca STATE OF UTAH 1 DEPARTMENT OF HEALTH }I QEPARTMENT OF HEALTH ATE OF DEATH 219. PLACE OF DISPOSITION (Name of cemetery enmatory. or other place) Cokeville City Cemetery 401111?ccurred at the time. dale, and place. and due to the cause(s) and manner as elated. pasis 0) eaaminallon and /or investigation, In my opinion. death occurred at the time, Q �9 A0)4.IrEM 2fl (T,yer ➢rwl bad; Kaysville, Utah 84037 CAUSED THE DEATH. DO NOT ENTER THE MODE OF DY1010. SUCH AS CARDIAC 'r ON EACH LINE. 39.1 %0U' OPINION. TOBACCO USE BY THE DECEDENT 'l t P 9bably contributed to the cause 0) death. 05. NON USER 9 'Kips the underlying cause o) death. 1 1 9.not contribute to the cause of deal. e4nl m relation to the cause al death. 0 6. UNKNOWN IF USER D fester sequence of event, 24. FUNERAL HOME INanw. Lindquist's ;"-Nangle TOR OF VITAL RECORDS. STATE FILE NUMBER 35c. INJURY AT WORK? 0 ?Yes 2. No address and license number) 27c. LICENSE NUMBER 7B.IG/9n/-1PS 30e. DATE REGISTRAR NOTIFIED OF DEATH (Mo..Ooy.Yr) June 30 1998 i'n this office. This certified copy is issued ;-1,953 As Amended. 11 IIIIIIII11I11 n eyIttit-tAYI 0 0 5 2 6 5 3 9* 21z LOCATION City or Town. Stole k WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES A)JY ALTERATION OR ERASURE VOIDS TIIIS CERTIFICATION Ely 96 Cokeville, Wyoming Clearfield Mortuary #44 1050 So. State Clearfield, Utah 84015 276. DATE SIGNED (Mo.. Day, VI) 30.71' 306. DATE FILED (MO.. Day. yr) Jul 1 1998 Approximate Interval Between Onset and Death 35. WERE AUTOPSY FINDINGS AVAILABLE PRIOR 00 COMPLETID! OF CAUSE OF DEATH 02N 35d. PLACE OF INJURY Al home. larm, street. lattory office. building.ete. (Soeny) 351. II motor vehicle accident specify if decoderrl was driver. passenger or pedestrian. Ich resulted in injury. NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31) d =S y 1 8 9 6��1�' ATE OF UTAH DEPARTMENT OF HEALT W IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES ry 4 ?T' ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION T M; :1 L /!e,09d/d6!/ ///9C,4L[gC99Y/ d$Jh::wccurred at the time, date, and place, and due 10 the *auu(0) and manner as stated. ?jp bU•tYC of examination and/or Invesllgatlon, in my opinion, death occurred al the time, a. DATE OF DEATH (Mo. Day, Yr.l Male July 8, 1998 BIRTHPLACE (Clry a Slate of Foreign Coondy) Co alville, Utah f NTB USUAL OCCUPATION (Glee kind of work done ''Most of lrorklnp the. Do NOT use retired) v:il Service 102. No 15. RACE Black, While, Am. Indian (Tribe may be entered), Japanese, etc. (Specify) ,SPeeiIT) White ms. Mary N El i enStaley Middle, Lae Or.. PLAC OF DISPOSITION (Name of 21c. LOCATION City or Town, State 'a.cemehry, comer.%, or other place) Cokeville Cokeville, Wyt f(.EMxl)T I'd Ka ysville, Utah 84037 30a. DATE REGISTRAR NOTIFIED OF DEATH (Mo..Dey, W..) �`7VIE`b DO NOT ENTER THE Ay6E* N EACH LINE. 1741 W. Phillies Street SURVIVING SPOUSE fir wee,pive maklen name) s' INION, TOBACCO USE BY THE DECEDENT .tote contributed to Ms caused death. LT 5. NON -USER 61e-iM dedying cause of death. contribute to the cause of death. 6. UNKNOWN lit re 46on to the cause of death. IF USER (yaanter eeguence of events which resulted In injury, NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31) thi8,office. This certified copy is issued 153 "As Amended. ii?'s✓� Nangie 0i 'OR OF VITAL RECORDS oIII IIIIII2 6 IIIIIII1 By 1 9 1 �I 4 m r 0 0 b. NAME OF HOSPITAL, NURSING HOME OR OTHER FAC 1 (11 outside laci*y plea skeet address of location) 16. EDUCATION (Spec) y only highest grads completed) Elementary or Secondary (0.12) College (1316 or 17 q -14- Clearfield Mortuary #44 Na 1050 So. State Clearfield, Utah 84015 27c. LICENSE NUMBER 27d. DATE SIGNED (Mo., Day, W) Jule 10, 1998 33b. WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? ❑I. Yee 0 2.No 35d. PLACE OF INJURY At home, farm, street, factory, *Mica, building,eto. (Specify) 51. M motor vehicle accident specify If decedent was driver, passenger or pedestrian.