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TYPE
ON PRINT
PERMANENT
BACK
INN(
FOR
INSTRUCTIONS
SEE
HANDBOOK
INFORMANT
DISC' SITION
VR 2 -89
4/94 15M
LOCAL FILE NUMBER 1011
1. DECEDENT -NAME FIRST MIDDLE
William
4. SOCIAL SECURITY NUMBER
520 -03 -8855
7a. PLACE OF DEATH (Check only one)
ISlnpalient 0 ER /Outpatient 0 DOA
7b. FACIUTV NAME (g not Institution Oro seed and number) 7c. CITY. TOWN, OR LOCATION OF DEATH
South Lincoln Medical
8. STATE OF BIRTH (d net In U.S.A., name country)
Wyoming.
11. NOS DECEDENT EVER IN U.S. ARMED FORCES?
(Speedy yes or co)
No
13a. RESIDENCE STATE
Wyoming
134. INSIDE CITY LIMITS?
(00.cify yes or no)
Yes
17. FATHER'S NAME Fest Middle
18.. INFORMANT -NAME (Type or pint)
Joseph Thornock
19c. MAILING ADDRESS STREET OR R.F.D. NUMBER
20a. Buda) Cremation, Removal
from State. Other (Specify)
Burial
CERTIFIER
CAUSE
OF DEATH
21a. FUNERAL SERVICE BEE qs Person Act umber
85
22a. To the best of my knowledge, de curred at the lime. date and place and due
to the cause(*) stated. r'r"
(Signature and Tide)
#ti. G91 G
220. DATE ED (Mo., Day, Yr.) 22c. HOUR OF DEATH
.t-Lr L -C. l 9 5 l4 oo M
22d. NAME ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (T p. cur Print)
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)(Type a Print)
250. REGISTRAR
(Sigma..) 1111.
PART I. Enter the diseases, Intones, or
25. or respiratory arrest, shock,
IMMEDIATE CAUSE (Final
disease or condition
resulting In death) 4
Sequentially lift conditions,
Y any, leading 10 Immediate
cause. Enter UNDERLYING
CAUSE (Disease or Injury
that Initialed anima
resulting in deem) LAST
PART 8. OTHER SIGNIFICANT
010k2 ,tale
28. MANNER OF DEATH
Nalusal
Accident
Teresa P. Borino M.
Stickle
Homicide
William Bosworth
a
Lea,t i ttL(e t t� CD (fi J
30a. DATE dF INJURY 308. TIME
(Month, D.y, Yew) INJURY
Pending
Investigation
"'Could net be
Determined
13b. COUNTY
y
Date Issued
Bamforth
1 91110.
6a. AOEdast Birthday
(Team)
0 Nursing Home 0 Residence 0 Other (Specify)
Center
97
Lincoln Diamondville
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Speedy no or ye. II yes, speedy
Cuban, Mexican, Puerto Roan, Etc.)
SI Yes 0 (SPecily)
1318
200 DATE (Ala, Day, Yo.)
June 13,1995
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Last
Ball
Mom8e
g. MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED Speciy)
Widowed
12a. USUAL OCCUPATION Moe kind o) work done during most
d working life, even N retired)
Coal Miner
(3c. CRY, TOWN OR LOCATION
3rd West Kemmerer
20c. CEMETERY OR CREMATORY -NAME
21b. NAME OF FACILITY
Moose 6
DUE TO (OR AS A CONSEQUENCE OF):
Is
DUE TO (OR AS A CONSEQUENCE OF):
a
DUE TO (OR AS A CONSEQUENCE OF):
Ball
50 UNDER 1 YEAR
Onyx
„t N 2 n 19c3
LAST
Days
gone but cTused de am. Do not enter the mode 01 dying, such as cardiac
rt failure. List only one awe on each Ilna.
M
30e. PLACE OF INJURY -At home, Term, *treed, teeth,
office building, etc. (Specify
Hours
Kemmerer
2. SEX
Male
6c. UNDER 1 DAY
Minutes
10. SURVIVING SPOUSE (If rite, give maiden name)
18
None
d.
DITIONS- Conditions contributing to death bur not related to cause given in PART I.
E'.iLl C eii �l Lan
Coal Mining
13d. STREET AND NUMBER
313 Paper Collar Row
15. RACE American Indian, 16. DECEDENT'S EDUCATION
Black, White, Etc. (Speedy only highest Wade completed)
(Speedy)
White
MOTHER'S NAME
CITY OR TOWN STATE
30c. INJURY AT WORK?
(Specify yes or no
Number
Crandall Funeral Home 28
230. DATE SIGNED (Ma, Day, Yr.)
23d. PRONOUNCED DEAD (Mo., Day, Yr.)
22Le,&layaseu1a,.r at e ck ti:�
4 13
STATE FILE NUMBER
3. DATE OF DEATH (Ma, Day, Yr
June 10. 1995
8. DATE OF BIRTH (Ma, Day, Yr)
Sept. 2 1897
12b. KIND OF BUSINESS OR INDUSTRY
7d. COUNTY OF DEATH
Lincoln
Elementary /Secondary (0.12) College (1.4 or 5
9
F MMdo Malden Surname
Millicent Bower
(86, RELATIONSHIP TO DECEDENT
Nephew
ZIP CODE
210. ADDRESS OF FACILITY
June 14., 1995
Purdy
Wyomin 83101
Od. LOCATION CITY OR TOWN STATE
Kemmerer Cemetery I Kemmerer, Wyoming
Kemmerer Wyoming 83101
230. On the beak d examination and /or Inveatig0lon, M my opinion death occurred
at the lens, ate and place and due to the auee(e) stated.
(SIV A. and TWO
23c. HOUR OF DEATH
Kemmerer, Wyoming 83101
25b. DATE RECEIVED BY REGISTRAR (Mo., Day, W.)
23e. PRONOUNCED DEAD (How)
Appmdma1e
I Interval Between
Onset tad Death.
4P6q 6 !I; id
27. AUTOPSY (Specify 28. WAS CASE REFERRED TO CORONER
Mr or ma, (Speedy yes or 10)
No No
30d. DESCRIBE HOW INJURY OCCURRED
301. LOCATION (Street and Number or Rural Route Number, City or Town, Stale)
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.
Deputy State Registrar
M
M