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DNIWOAM 40 31VIS 3H1
State of Wyoming
County of Lincoln
The foregoing instrument was acknowledged before me by June F. Nield this day of
July, 2000.
Witness my hand and official seal.
Mf IM$ L. HALE NOTARY MUG
.outuY OF
U C @LN
STATE OF
WYOMING
1Pd Cuaiulw £z$u AM 2, 2011
My Commission Expires:
s//0 ev/
086711.4 074
PART R, OTHER SKGNITICANT CONDITIONS: CONDITION} CONNIIIN1114 10 044144
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HOW INJURY OCCURRED 1 1NT14 N4 OT 1N10b 1N 4441 104 •611 0, r4N I! 1
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GR CORONER: 04 TNT 1414/01 1 I NOUN OT MAD/
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1.••■■•1'0N 01 MI 1100! END /011 NO INTINIOA!NJN, IN 444 0004014,
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LAWRENCE, J. COHEN, M. D.
STATE REGISTRAR
THIS IS TO CERTIFY THAT THIS REPORDUCTION IS A TRUE COPY OF A RECORD ON FILE IN 0 5
VITAL RECORDS SERVICES, DIVISION or HEALTH AND MEDICAL SERVICES, WYOMING DEPARTMOLT,
OF HEALTH AND SOCIAL SERVICES, CHEYENNE, WYOMING. v
8 14,11 v...4t., NtOW. 14.141(10.4 1«0•.14,
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AGE -441'
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CITIZEN OF WNA.T COUNTRY
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STATE Or WYOMING
DIVISION Or HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
,74 41 t 44[41• 1 I C„ DATE 11 Of 111R4H 1 140441,1,
woo. wr1 nOV.1 rw 1461
■0 :•I: n Sl� 11 aira.coln
411 (IN Linn OSAI nPIT R OTHER RJliITUTIUN -NAM ro 44440 IN 1 •nH 4144 1
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U.S.A. to is rr ied n. June S :444-
USUAL OCCUPATION .411.4 .w.0 woo* 00..1 N.4.44.0 0,014 Of KIND Of RUMNESS OR INDUSTRY w
OM `.O (0411 or NTNC11
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MAILING ADDRESS
I NIO4MANT -NAME
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TART 1 DEATH WAS CAUSED 11Y:
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AILIN 60081155 CERTIFIER
OURIAL, CREMATION, REMOVAL
srtclh 4
74* Burial
DATE 1 440«114, 044, NMI I
f6. /t'01 I.I.D NO
CEMETERY OR CREMATORY -NAME
LAST
VITAL RECORDS SERVICES
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e- 1-\ 1 440! N0•••'1
DA1l L./? 4. LAI/l 1 «0111,,. par, u6A
1 1.1.9.1 Alt 2 5 l(:'
COUNTY Of DEATH
1141,
1314
m 110 (0. 110.14
41 411 00 rp
144
MOTHER MA LIN NAME nq
STREET AND NUMO(R
14.
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111011 04 4.1.0. 140, (111 04 t04*14, •041, IHI
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LOCATION
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n
0411. Afton, Cemetery NI. A,L r
ton R Wyoming
p FUNERAL HOME -NAME AND ADDRESS 4 04 4.I.0. NO., (NV 04 100144, fun, 2414 I
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fUNCR/SL DUCtfOR- SIGN I .fi REGISTRAR �.;1711k
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LOST
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