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JNIWOAM 30 31V1S 3111
1. DECEDENT -NAME FIRST MIDDLE LAST
Helen Fraley
2. SEX
F
3. DATE OF DEATH (Ale.. Day. Yr,)
July 20, 1993
4. SOCIAL SECURITY NUMBER
520 -52 -8073
5a. AGE -Last Birthday
(Yeas)
45
6b. UNDER 1 YEAR
50. UNDER
1 DAY
e. DATE OF BIRTH (Mo., Day, Y..)
October 7, 1947
Months Days
Hours
Minutes
TYPE
OR PRWT
IN
PERMANENT
BLACK
WK
FOR
INSTRUCTIONS
SEE
HANDBOOK
DECEDENT
INFORMANT
DISPOSITION
CAUSE
OF DEATH
VR P -89
2491 15M
tissue►:
LOCAL FILE NUMBER
+4
7.. PLACE OF DEATH (Check only one)
Inpatient ❑ER /Outpatient 0 DOA IOTHEI:
aNUraing Monty Residence Other (Specify)
78. FACILITY NAME (11 nor institution, give street and number) 7c. CITY, TOWN, OR LOCATION OF DEATH
St. John's Hospital Long Term Care
S. STATE OF BIRTH (ll ne m USA., name country) B. MARRIED, NEVER MARRIED,
WIDOWED, DNORCED (Spool!
Wyoming
11. WAS DECEDENT EVER IN US ARMED FORCES?
(Spec( /y yea or no)
13a. RESIDENCE STATE
Wyoming
3a. INSIDE CITY LIMITS?
(Sp.olly yes or no)
Yes
17. FATHER'S NAME First Middle Lost
19c. MAILING ADDRESS
No
Lowell
19a. INFORMANT -NAME (Type or RUN)
13b COUNTY
200, Burial, Cremation, Removal
Inn Stale, Other (Specify)
Burial July 2
21a. FUNERAL SERVICE LICENSEE Or Person Acting
A. Soc. (Signature) !,r
2 A knowledge,
it to the camels) staled.
(Signature are Title) I►
y 2 20. 0.17E SIGNED (Mo.,
lip A
E
Lincoln Afton
Kenneth Fraley
19 WAS DECEDENT OF HISPANIC ORIGIN?
(Specify no or yes If yes. specify
Cuban. Mexican, Puerto Rican, Etc.)
No ei (SpecllY)
Jensen
STREET OR R.F.D. NUMBER CITY OR TOWN STATE ZIP CODE
PO Box 363 Afton
20b. DATE (Mo, Day, Yr.)
1993 Afton Cgme_tpry
Number 21b. NAME OF FACILITY
452
Valley Mortuary
tuned at the t�nd place and due
44-
22c. HOUR OF DEATH
�3 0800 M
22d. NAME OF ATTENDING P "CIAN IF OTHER THAN CERTIFIER (Type or PUN)
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)(Type or Print)
11
DATE RECEIVED BY
Richard Su den M.D. 555 E. Broadwa
25a. REGISTRAR
(0440. E c
PART I. Enter the dl.08.68. Injuries, or complication. that cawed m. Do not enter me of dy such as cardiac
28 or rsepralory arrest shock, or heart failure. List only one on each Ma.
IMMEDIATE CAUSE (Final
disease or condition
resulting In death) n)
Sequentially list conditions.
II any, leading to immediate
caum. Enter UNDERLYING
CAUSE (Disease or (Nury
that Initiated events
resulting in death) LAST
20. MANNER OF DEATH
X Natural El Pending
Investigation
Accident
Suicide Docile not be
Docile
Homicide
Date Issued August 17, 1993
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Married Kenneth Wayne Fraley
12a. USUAL OCCUPATION (0've kind ol work done dying most 128. KIND OF BUSINESS OR INDUSTRY
d working Ws, even d retired)
30a. DATE OF INJURY
(0(0,118, Day, Yowl
Waitress Food Service
13. CITY. TOWN OR LOCATION 13d. STREET AND NUMBER
20. CEMETERY OR CREMATORY -NAME
k2.1> \O (2� I t" -A C'r) Iz-'1
UE TO 109 AS A CONSEQUENCE O
sO (OR AS A CONSEQUENCE OF):
30b. TIME OF
INJURY
30. PLACE OF INJURY -Al tame, farm, street. factory,
office building. etc. (Speedy
Jackson
10. SURVIVING SPOUSE DI wile, give maiden name)
15. RACE American Indian,
Black, White, Etc.
(Splee(Y)
18. MOTHER'S NAME First Middle Malden Surname
230. On the bean of exandnatlon and /or Investigation, In my opinion death occurred
at the tine, date and pace and due to the cause(s) Meted
a (Signature and TAN)
23b. DATE SIGNED (Mo., Day, W.)
p
E 23d. PRONOUNCED DEAD (Mo., Day, W.)
Jackson WY
M
White
67 S cond East
Maxine Dana
300 INJURY AT WORK?
(Sassily yes or no)
19b. RELATIONSHIP TO DECEDENT
Wyoming 83110
Number
117 Box 9059, Jackson, WY 83001
25b
Elementary /Secondary (0 -12)
12
Spouse
STATE FILE NUMBER
16. DECEDENT'S EDUCATION
(Specify only highest pads completed)
200. LOCATION CITY OR TOWN STATE
Afton Wyoming
21c. ADDRESS OF FACILITY
REGISTRAR (Ma, Day, W.)
q. 199
Approximate Be
Interval Between
Onatit n.el and Death.
1e_ s r
S P 1 rz -1- S�
F FLc.
DUE TO (OR AS A CONSEQUENCE 0 X
PART 8. OTHER SIGNIFICANT CONDITIONS CondRbna contributing to death but not related 10 cause given In PART L 27. AUTOPSY (Speoldy 28. WAS CASE REFERRED TO CORONER
700 or 00) (SpooUy yes or no)
No No
Od. DESCRIBE HOW INJURY OCCURRED
301. LOCATION (Street and Number or Rural Route Number, City w Town, State)
THIS IS TO CERTIFY that this reproduction is a true
copy of a record on file in Wyoming Vital Records
Services, Cheyenne, Wyoming.
This copy is not valid unless it bears a raised
seal and the signature of the Deputy State
Registrar is in red.
e
,Z./-75,
Deputy State Registrar
Teton
466
7d. COUNTY OF DEATH
College (1 -4 or 69)
23c. HOUR OF DEATH
230. PRONOUNCED DEAD (How)
1 T
M
M