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8182 IOM
DECEDENT
PARENTS
CERTIFIER
CAUSE OF
DEATH
RESIDENCE -STATE
1,,. W Y 0
OTHERBURIAL, CREM REMOVAL,
(S pei
18•.Buriel
FUNERAL SERVICE LICE EE arson&Awe
As SudN Sign/dun/
(Signature and Title)
14- and due to dm
P
HOUR OF DEATH
210. 21e. 4
NAME OFA a r DING PHYSICIAN I OTHER THAN CERTIFIER I pe or Print)
228. 0.m. pasha of aaanunatan Ardor nveatgaaon, in my opmwn oe
dab and plan and due ntbww(s) stated.
HOUR OF DEATH
OCC.a. d MIN bow.
TYPE
OR PRINT
IN
PERMANENT
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
IF DEATH
OCCURRED IN
INSTITUTION,
SEE HANDBOOK
REGARDING
COMPLETION OF
RESIDENCE ITEMS
CONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
25.
PART
i
Date Issued
DECEDENT -NAME FIRST
LAST
1. 1 n'1Te Elmira
RACE -is g Mute. Black. Amsncan ORIGIN OR DESCENT fe g !Wan. 'Amman, AGE Last p w n R1 t A N R
Indio,. •10 (Spc. fyl German Poem Run. EnSxsn. Cuban. aoc.) IYnJ y UNDER t YEAR UNDER 1 DAV
ISp rlfN texas I a s
a White 48. FNg1 i s -Scare Sa. R2 SA. 1 I
PLACE OF DEATH- Hospnl ar other IrsmworvName I! o IF n 1 ON I
.n g1.e street number, �f OSP OR *1ST Inonla DOA, CITY, TOWN OR LOCATION OF DEATH
star a r Valley OP Emr Rm_wPtoam
7 Hospital Inpatient Afton,
STATE OF BIRTH .n U. CITIZEN OF WHAT COUNTRY MAR 7 c
name country/ MARRIED NEVER MARRIED.
Utah 'AnDOWEO, DIVORCED /Spay,
S. e. U.S.A. 10 Married
SOCIAL SECURITY NUMBER
13 520 -34 -9003
CITY. TOWN OR LOCATION
Afton
FATHER-SIMIE FIRST MIDDLE LAST
18 Chester Frederick Campbell
INFORMANT-NAME Tree*, Pr.D
11a.
REGISTRAR
24a.
(c)
Harold Papworth
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER) l Type or PnrD
23.
Signature,
LOCAL FILE NUMBER
(t) "th c' fl •5 171
DUE TO. OR AS A CO EOUENCE OF
DUE TO. OR AS A CONSEQU ENCE
CQ.4
ACC.. SUICIDE. NOM. UNDET,
OR PENDING INVEST ISpm.fy/
281.
INJURY AT WORK 'Sprier
Hrie Yes
tea.
211.
lb.
April 16, 1987
MDaE
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVIDEn
CERTIFICATE OF DEATH
USUAL OCCUPATION Moo kind of uork done dunk Nara(
awning GA. r.en if named!
Teacher
14a.
MAILING ADDRESS
180. box 1 4
DATE WA. Day. Yr., CEMETERY OR CREMATORY -NAME
IMMEDIATE CAUSE (ENTER ONLY ONE LALISE FLERLiNE FOR fVA(DJ ANOfc /J
t( Ure
ply cY
t/1A..(Q I
PART 07i SIGNIFICANT CONDITIONS-Condrbons n^I to dean, to 10 notated to name oven ul PART I (a)
11 J
288.
SURVIVING SPOUSE /tf only. dor eludes rare,
71 Harold Papworth
MOTHER MAIDEN NAME FIRST
17 Lettle Dewey
STREET OR A.F.D. ND.
228.ON
!STREET ANO NUMBER
4 lSggnoture and T(tfe) S
a DATE SIGNED Mo., Day. Yr.)
3
a
Ob 17354
SEx
148
1s 36 w. 4th
248.
OCATION
PRONOUNCED DEAD (Mo.. Day. Yr.,
AUTOPSY ISpc.fy Yes
/J Not
P ia"' E n O ea 1'e n. NO
DATE O f INJURY (Mo.. r.I HOUR OF INJURY DESCRIBE HOW INJURY URY UR uaxe0
280. 28a. 11 2$d.
PLACE OF INJURY At home. hon. shrew, tarry, 0lbCS blydahS LOCATION
Mc_ 1Spec./,! STREET OR R.F .D. No.
Deputy State Registrar
STATE FILE NUMBER
DATE OF DEATH ,No.. Da., Y
3 April 4 1987
DATE OF BIRTHlhq Da•. Yr
Sept.25, 1904
I MO OF BUSINESS OR INDUSTRY
Education
MIDDLE
CITY OR TOWN STATE
Afton, WY 83110
CITY OR TOWN
221. AT
I DATE REL{d VEp�RE01ST Mo. Oar. }'r.
CITY OR TOWN
THIS IS TO CERTIFY that this reproduction is a true copy of
a record on file in Wyoming Vital Records Services, Cheyenne,
Wyoming.
If this copy does not bear a raised seal and the signature of
the Deputy State Registrar is not in RED, this is not an official
certified copy.
COUNTY OF DEATH
Lincoln
WAS DECEDENT EVER IN U.S
ARMED FORCES,
Speniklt or.Veu
I INSIDE CITY LIMIT
rSper.f. Yes or Hai
15s. y G�
LAST
PRONOUNCED DEAD, Hoer,
1 Interval between Gnaw NM oe
i sm rv\a
I interval bermon onser 1110 der
0 di
1nteny nansel de
624
aP
STATE
WAS CASE REFERRED TO CORONER
I Spee.fv Yn or ,Vo,
27 NO
STATE