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STATE OF UTAH DEPARTMENT OF HEALT
WARNING IT IS ILL AL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES.
G'th s S`bl ANY ALTS` ATION OR ERASURE VOIDS THIS CERTIFICATION.
CERTIFICATE OF DEATH r
STATE OF UTAH DEPARTMENT OF HEALTH
1 7 1 !1
1 1 ---TTT STATE FILE NUMBER
LAST SEX RACE (White, Black, Am. Indian etc.) DATE OF DEATH (Month,Day,Year)
Specify
BEVERLY JEAN: GREEN;`HEATON z. Female 3. White
WAS DECEDENT OF SPANISH CI I YES -�10 If y e'a; I ndtcata tut): DATE OF. BIRTH (Month,Day,Year) AGE (Last
Mexlcen❑ Puerto Rican:: Cuban Othef (1) oth6,, epecIfy)' Birthday)
5.
NAME OF DECEDENT FIRST
BIRTHPLACE (State or foreign country)
USUAL OCCUpATION kind of Work don 4trt
working llfe, ;even retired.)
13a Homemaker
NAME OF ATHER
;Sheldon John Gr een
USUAL RESIDENOE- (Street addras;dor roeaboh,)
=1471 West 4180 Sout
ITY OR TOWN ICOUNI T)t`'
Tay_lorsville
2
PART f; DEA H WAE'" AU$ED
Date, Issue
A3her: f -123uJ Un a
NAME AND LOCATION "OFCEMETERYLSR CREMAT
Valley Vieww Mem,
Y: ''IMM DIAT CA
(A)
'CONDITIONS VAN) WHICH DAVE RISE;TO
THE IMMEDIATE CAUSE,'
(A), STATING THE UN=
>DERLYING=CAUSE ],:AST:'
(C)
PARTS. OTHER SIGNIFICANT CONDITIONS C0
IMMEDIATE CAUSE GIVEN IN PART),
is is to certify that this is a ti
cier" ar thority,of section: f3-2
MID
DESCRIBE HOW INJURY, OCCURRED (enter eegdenjcd of
SHOULD BE ENTERED ;IN ITEM 29) i
39.
0 What co
Utah n
me which
Nay 2, 1928
Never Married
Married Widowed
10. Divorced
'I1oND OF BUSINESS OR INDUSTRY
CE OF
Home
'INSIDE CITY LIMITS?
I YES NO
118b.
(STATE AND ZIP CODE
NAME of hospital, nursing home or other inptftdti n yrherq q Ih 9c cufred.' CITY OR TOWN
Of outside an institution, give street address df lopation) Inpatient E.D. patient 1
20s-" Cottonwood Hospita DOA 120b. Murra
MEDICAL EXAMINER: 1 hereby certify that (d the` peat of n y'coley/ler:101Me: ^.oath occurred e. at the ndlor, hour,
date and place stated above 'rpm the.cau6ee stated below bend on exam nation of "th 7ody
Investigation p1 the circumdtantes.. to
Decedent was ;cro '•unced dead att.f -to
22. HOUR MO i DAy
R
Burial Entombment❑IDATE
Remova Cremation
RI�UT�NG�TO;DEA 3IIT NOT RELATED TO THE
Accident "Pending, eat)gatiorf DA o In)ui'y (Monfh,Day, Year)
surcide Undetermined tf tp urad
Homicide o Accidently Or PuOge)yr 33a
LOCATION OF itoart -STREE'r'AND;NUMRbR OR Y rimif N`A
f(D t:IYY O TdWN.
MAIDEN NAME OF MOTHER
Edna Howarth
Utah 84107
!PHYSICIAN 0
er line for Baand
i9 r C8 0
7 .54 Yrs.
y of the cer ilicateon file in this office. This certified copy is issued
he Utah C Annotated, 1953 As Amended.
Barry `E, Nangle
DIRECTOR OF VITAL RECORDS
Months I Days
IF UNDER 24 HOURS
Hours I Minutes
EDUCATION (Specify only highest grade completed) SOCIAL SECURITY NUMBER
Elementary or Secondary (0-12) College (13-16 or 17
11. 12 12. 259 -30 -3554
NAME of surviving spouse (If, wife, enter maiden name.)
Was decedent ever In U.S.
Armed Forces?
17, YES n NO
I i, _R
NAE `ATIQSIS7 NG DDRESS OF INFORMANT
r. Kerr r/ Heaton, husband
1471 West 4180 South 18 _Taylorsville, UT 84107
GNATURE
WV 4 6
1: •r 1 21b.
ere y Bert y at to t e est 9 my kn9wIed9e the'death occurred at 1..ERT IER'S name and title (Type or print) DATE SIGNED (Month,Day,Year)
the hour, date and place,Statsrl above from the tause etated,4Alow, that 1 attf,pded the el
decedent, and I1 month f�, 4„ r(f a llva 4n I r/ Y1tr yy �s p y al 1 211
31d m month T /A' 1 j j d�y yeas 3 1 21s. uhr ord R. i L CiSe 1 r 1 1
f
If not certified by medical examine Was death reported to him? YES NO
t CE RTIFIERS address and zip code !UTAH PHYSICIAN
II yes enter the date and now reported: (24 Aour clock) LICEN E NUMBER
YE hR 1219.
1 S. 30 1... i i tA r 1 ON 1A+ t Io 7 L m 1 49
"SIGNT otTOnerai ecto FU R HOME—..me ddress and ll ns umber
254838u�5 P e5woe d .hmeSLC UT 84107
Date accepted for registration by
local IEZ kt 28 J u a 2 1983
AUTOPSY 1 IF YES, were findings cons(dered
YES death?
ICI.. to determining cause of deat
31a. I 1b YES NO
clock)
Interval between onset and death
A
Interval between onset and death
Interval between onset and death
TIME OF INJURY 1 URY AT WORK? PLACE OF INJURY (Specify home, farm, factory, freeway,
1 (24 Hour Clock) YES NO street, office buildings, etc.)
1 3b. 34. n n 35.
Distance from place of injury to Were laboratory tests done for Ware laboratory testa
usual residence (Item 16) drugs or toxicicals? 38. ne tor alcohol? ho� NO
136b Miles 37 YES NO
'ul(d hi Injury;" NATURE OF INJURY If motor vehicle accident, specify
if decedent was driver, passenger
or pedestrian.
40.