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PAPEN10
All A 1t:I1
CERTIFICATION O F VITAL RECORD
1111 004,10(11
0101 05111011
01 01111011
GAUP-(
ni 1)1 Atli
AAUP
DEANA
4. SOCIAL SECURITY NUMBER
528 -52 -9733
7.. PLACE OF DEATH (Check only one)
MOM., xle Mp•Sent ER /Ootp•tisnt DOA I B
7b. FACILITY NAME (8 not AreYOOOn, pet street and Nener)
ST. JOHN'S HOSPITAL
B. STATE OF BIRTH (x nar N USA., name sourly)
WYOMING
13.. INSIDE CITY LASTS? 1e. VAS DECEDENT OF HISPANIC ORIGIN?
(SOeo)ly a no) (Spscx a R wcxv
NO Cuban. ek 0. Furto Rio.. E(al
NX y1e 4 (BpeaCy
17. FATHER'S. NAME Firs Mdd8 Las
MAX HYMAS. NELSON
20a. Burial, lrpma xoh.;ANn ,104
from s
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONeftifrWS or PFInt)
LOCAL FILE NUMBER
8aprm14 )W conditions.
x easy, wading to Immetlar
use Enter UNDERLYING
CAUSE (Odin. es INury.
Bra billeted event
suiting in death) LAST
044033
22d. NAME OF ATTENDI
DATE ISSUED: JAN 1 6 1998
0. MMRRE D, NEVER W4101 0.
WIDOWED, DIVORCED
MARRIED
13e. CITY, TOWN OR LOCATION
AUBURN
OF DEATH
DUE 7O (OR AS A CONSEQUENCE OFX
30a. DATE OF INJURY 30b. TIME OF
(Month, Day, 1M)
.NOt0Compr ur
WORTON
ab UNDER 1 YEAR'
MITT B. OTHER SIGNIFICANT CONDITIONS- Canatiou contributing to death but not related to caw given In HURT).
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DEPARTMENT OF HEALTH ok C
STATE OF WYOMING 470 q h r 2 1 0
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
2001 GATE MA. 094 riJ' 220 CEMETERY OR CREMATORY -NAME
CTOBER 28 1996 AFTON CEMETERY
Person AanS r 2 1b:' NAME OF FAC)LJTV
SCHWAB MORTUARY
rbdgs. d. r, q l) V der pro. and gue
11. WAS DECEDENT EVER IN U.S ARMED FORCES? 126 USUAL OCCUPATION (0N, ,o0(1 w0 dale 0001g Most yee or no)
a waklp awn E "red dl
7e. CITY, TOWN LOCATION OF DEATH
JACKSON
10 SUNNING SPOUSE!)! Meta, gele maiden name)
EUGENE ',WORTON'
25a. REGISTRAR
(3Qtetae) a./, el. 1 A )t 141\
MIT 1. Enter the disease., (*dent, or complications that calmed death. Do not enter MO Moo. i1 dying, such as lac
20. or respiratory arrest, shock or heed r.90, UM only one dew an seen W+
MEDIATE CAUSE IF1nal f y.Ar�
dews or condition
sedans In death) 9 0
■1 N
DUE 70 (OR AS A CONBEQUE OF):
DUE TO (OR AS A CONSEQUENCE OF):
13 140THEWS -NAME First 1 "M Marro Brume
ADA HURD
180. INFORMANT•NAME (7Bre qr NAX1 18b. RELATIONSHIP 10 DECEDENT
EUGENE WORTON HUSB1>N
19.1.4A STREET OITR F. NUMBER �C )TY'00 TOWF( SDGE r ZIP 00DE
244 TOO ANYON ROAD AU.BXJ WY MI G
306. INJURY AT WORK?
(Speedy yes w no)
2. SEX 3. DATE OF DEA7H (M., Day, Yr.)
FEMALE
Sc. UN00R 1 DAY
OCTOBER 23, 1996
6. DATE OF BIRTH (Ma, Day, W.)
MAY 3, 1938
120. KIND OF BUSINESS OR INDUSTRY
TAX SERVICE
(3d 87REET AND NUM
244 TOMS C ANYON ROAD
it..DECEDENT'S EDUCATION
(Sp.cIIy enlY NOW 09
ga ry ,(0- 12)College (1 40 .0 7
'AFTON
NumWr 21c ADDRESS OF P.147k.ITY
45 44 E. FOURTH AVE, AFTON
On 6e 6.61 el aoo,dnIl(on and/or 7n.ssx2s in re p op(No. 666 0 00.999
.y the 1 erd p
9±r Nie. 999 dus 10140 09'l.99(9) ela16I,'
(812x66: *DX 89111
238. DATE SIGNED� Day', WJ 23e. HOUR OF DEATH
MICHAEL MENOLASCINO MD. 555'E. BROADWAY 'JACKSON, WYOMING 83001
2 T RECEIVED BY REGISTRAR (AO., Dar riJ
tl -9 -9(e
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
STATE 7115 NUMBER
Lucinda McCaffrey
Deputy State Registrar
7d. COUNTY OF DEATH
TETON
CITY`.0R TOWN STATE
WYOMING
M
23e. PRONOUNCED DEAD (Howl
27. AUTOPSY (Specify 28. INA8' CASE REFERRED TO CORONER
,w or 88) f$Paa/y »s or .0)
NO NO
30d. DESCRIBE HOW INJURY OCCURRED
301. LOCATION (Street and Number or Rural Route Number, City or Town, Saps)
0.a a 'i r i h
X gT w,ANY,ALTERATION OR
at
N) Q) R ltfitfl -rc
stlb)i1�T,S��1?.