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TASTE OF UTAH DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
PE50RIBE H WINJURY OCCURRED (enter sequence of events which resulted in injury, NATURE OF INJURY should be entered in dem 31)
his is to certify that�this is a true copy of the certificate. on file in this office. This certified copy is issued
nder`authority of section 26-2-22 Jf the Utah Cody; Annotated, 1953 As Amended.
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
By
1 NAM E, O FDECEO E M 'LAST 2. SEX 3a. DATE OF DEATH (Mo., Day, Yt) 3b. TIME OF DEATH (24 hr. clock)
D: B HUNS Male Oct. 22, 2000 1815
4 OAT.EOF SIRTH Edo D i 1 5 GE
A LOSI Bulhday l JI19ER 1 YEAR ,v 09405 21 FIRE o,
6. BIRTHPLACE (City 6 State Foreign Country) 7. SOCIAL SECURITY NUMBER
M0111,3 MUM UayMUM Mlnu es
September (s 1 8 L Collinston, Utah 520 -09 -8150
S C E �HOS ,totyyyod. S aA ALL OTHER LOCATIONS: 89 NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY
OF CNTH 1 il05gt rl a `f 5s Norsing Home 1 6 80,140508 (any) ('l outside a facility, give street address of f location) (cheap*, OW, r3 uIpaI,onl 3 OOA i 7 Other (speciy) Mt. Ogden Nursing Center
8c CITY, `tOW 0 LOCAT DEA 84 COUNTY OF DEATH 9 (1
SURVIVING SPOUSE l wile, 5190 maiden name)
0� I Weber Zelda Hepworth
ED
OECEN1 10 OC C ED d9 MARIT 7S T'A1 US 129. DECEDENTS USUAL OCCUPATION (Give k d of work done 129 KIND OF BUSINESS OR INDUSTRY
EVE 7 U L during most of corking 57.. Do NOT enter retired) ARME s1 }r 6v Manyd j 3 vndNaa Tax Preparation
1,Yes 1 2 No L XI2 Marr,.4 Eli 4, 0)vorded
Public Accountant and Accounting
1 3a RESIDENCE N 139. CITY, TOWN OR COMMUNITY 138 COUNTY 134. STATE
323 Adams Afton Lincoln Wyoming
130 189147 CITr 13 W ECEDENT 07 HISPANIC ORIGIN? 1. Yes 5J 2. No 15. RACE Black, While, Am. 18. EDUCATION (spedyonyhlghest
LIM 06 (1! yes, Spec 134103 (tribe may be entered), grade completed) Elementary or
Japanese, etc. (Specify) Secondary 0-12) College (1346
X 1 Yes Mexican 2. Cuban 0,11
2 rp 311 B 6 e4oR,ceo E] 4. olh.' (Specify) White 12
17 FATHER Mrojdls L 18. MAIDEN NAME OF MOTHER (Firs(, Middle, Last)
PAREN'
Ali Run g: Mary Ann Bowcutt
1 9 N RE MA( 4ING DDR
AESS OF INFORMAN
INFORMANT
Rhot1yi4 4H1µghter) Box 516, Afton, Wyoming 83110
20'METHOO OF DISYIT♦QN; 21X 67507 DISPOSITION 21b. PLACE OF OISPOSITION (name of cemetery, 21c. LOCATION City or Town, State
crematory, or other place)
i Enlogtbment 2r 3 Olhar'
DISPOSITION Xi 4: tuna( Rem004r.
��..,,rr, O ct. 26, 2000 Afton City Cemetery Afton Wyoming
22 SIGNATURE OF U NERAy I E 110914 23, LICENSEE NUMBER 24. FUNERAL HOME (Name and address)
426 Schwab Mortuary
24E'.0. !D T CEA$$,E 7 ?'6%1 1 �ended by toed'celexaminer, was 4.813 reported to M.E9 1.190, 2. N0 44 East kith Avenue
A EN 819 C+ER/TIN F7t119R(F1�I ,11 yes. enter 150 4,1.'and hour reported.
1t- CASE Jo H 4 1 5 0 9 10 DAY 30 YEAR 00 Afton, Wyoming 83110
37,,, CERT�FI R
1 CERTIFF P To thebfes y knowledge, death occurred N the erne, dale, and 71,, and due to the cause(s) and mann as staled.
GERf1FIER 2 MEDICA�L, E X N gEGLAW PAaRCEMENTOFFIC(AL: On the basis of examination Investigation, M my opinion, death occurred at the 9m e, del., place and due to the
cause(.) m o n g er es 81a)ed,
27b, BIO'1jA'!'UREANI5�7`ITLE d dJ)�ER 270. LICENSE NUMBER 27d. DATE SIGNED (Month, Day, Year)
169 3 l5'^ /o• 3o
2 NAME AND *140900 Of CERTIFI THE CAUSE OF DEATH (Item 31) (Typ.Thm1)
Harry �1<
iail; 1� #t. 425 East 5350 South, Ogden, Utah 84405
29 "REGISTRARI5 S(Gt j 'E E (JRE 300. AT EREGISTRAR NOTIFIED OF DEATH 30b. DATE FILED (M8., Dey,,Yc)
REGISTRAR gyp
��99 OCT 31 2000
31 PART 1 9NTER THE A S (INJURIES;" a R CCMPLICA 6NS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC Apprnaime(e Interval
¢R RESAT RY 9 887 59001. AR HEART FAILUR LIST ONLY ONE CAUSE ON EACH LINE. Between Onset and
Death.
IMMM QxU$ �1p I 11-01-4-1,..4
,n oJee e or C4ndlN4R t1 hg
nfJ @S(hj ,DUF, (OR AS ACONSE ENCE OF):
Pneumonia Days
S uentially l 51 cgndi To s 1
cause EnterU DE LY DUE TO (08 AS ACONSEQUENCE OF):
I
CAQSEildlsea6e 0 ry th DUE 70 (08 AS A CONSEQUENCE OF(
initial ,events reou(bng 0
488111) LAST
PART IL 0t5er8 grlRG( r/otrdlt co fw 10 4A0th 37. W YOUR OPINION, TOBACCO USE BY THE DECEDENT: 338. WAS AN AUTOPSY 339. WERE AUTOPSY
but het 180 11(05 m (h9 s' elIy r19 '''**1.9'146 n Par.1 PERFORMED? FINDINGS AVAILABLE
1 Probably contributed to the cause of death. 5. NON USER PRIOR TO COMPLETION
a.2. Meths underlying 00038 of death. OF CAUSE OF DEATH?
3: Rio nql .oniribule to the cause of death. 6. FKWOWN N 1. Yea 2. No al 1. Yes ri 2. No
4, la unknown In relation W the cause W death.
34 MANNER OF DEATH 35a DATE OF INJURY (MO Day, Yr.) 35b. TIME OF INJURY 350. INJURY AT WORK? 354. PLACE OF INJURY At home, term, 01,3.1, factory,
(24 Hour Clock) 1. Yee
III
2. No office, building, etc. (seedy)
A I. Natural Ap049M
�f 35,, LOCATION (Street or rural mule number, city or town, county and Stele.) 351. If motor vehicle accidgnt specify If decedent was driver,
"3. Suicide 4 H9micide- passenger 0, pedestrian.
STATE OF UTAH DEPARTMENT OF HEALT
1 .WARNING; IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES. 6
ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION r7 ,/,,,A
LAND TITLE COMP.
STATE OF WYOMING
as:
County of �.o.UAC,o
TEL: 13077336186
My commissio expires on: Feb. 26, 2002
Dec 28'00 6:46 No.024 P.02
690
On the J of November, A.D. 2000, personally
Bahr, Trustee, known or identified to me to be the appeared wh sef se, are s subs
to the within instrument, and acknowledged to me th she executed cuted the same cribed