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TYPE
011 PRINT
PERMANENT
Ha0N
P8(
FOR
INSTRUCTIONS
SEE
HANDBOOK
PARENTS
I rJropr.1AN
UISI C(ITIOr)
CAUSE.
OF LIEATH
\Y\h\\
LOCAL FEE NUMBER 1022
1. DECEDENT -NAME FIRST
Frank
4. SOCIAL SECURITY NUMBER
520 -16 -5175
74. PLACE OF DEATH (CAW, oak one)
South Lincoln Medical Center
8. STATE OF BIRTH (k real In USA., nom cotsery)
Wyoming
it MS DECEDENT EVER IN U.S ARMED FORCES?
(Spay yes or no)
Yes
13a. RESIDENCE STATE
Wyoming
13.. INSIDE CRY LMAITS?
(SWAY Po on no)
Sept. 15; 1999 .Kemmerer
21a. FUNERAL SERVICE UCEN E Or Pusan Ades Number 210. NAME OF FACILITY
As (SbtaW.)
0. -4/1' 429 Crand.
22 but of my a occurred d the fink dal
b the caw.(.) stated.
Benwm1ay IM eordkbr,
G ary. leading b InNrdats
we. Enter UNDERLYING
CAUSE Ip...tm or WIT
8141 Initiated a,.m.
rem/tine In death) LAST
20. MANNE11 OF DEATH
17. FATHER'S NAME Feat
John
075513
DATE ISSUED: 1 7 ICfi(
CERTIFICATION OF VITAL RECORD'
STATE O F WYOMING
130. COUNTY
STREET OR RFD. NUMBER
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
••VIA vu iswit
(Sarelve and 11th)
220. DATE Day.
J DUE OR AS A CONSEOUE
DUE TO 1011 AS A OUENCE
304. DATE OF INJURY
(Mach D.y, Av)
Lincoln Kemmerer
24. NAME AND ADORERS OF CERTIFIER (PHYSICIAN OR CORONERNTste or Pled)
X Craig Talbot MD, Moose
25a. REGISTRAR
(2a. USUAL OCCUPATION, (Oh. Aid or work done dung most 12h. KIND OF BUSINESS OR INDUSTRY
d rwrkng W., wan N nw0M)
Owner of Auto Repair Garage 'Automobile Mechanic
13c. CITY. TOWN OR LOCATION (3d. STREET AND NUMBER
Lad
Zebre
22d. H ATTE YSICIAN IF OTHER THAN CERTIFIER (T/po or Print)
Zebre
db. UNDER 1 YEAR
CITY OR TOWN STATE
Kemmerer, Wyoming
20o. CEMETERY OR CREMATORY•NAME
Funeral Home 28 Kemmerer,.Wyoming
7 21. on the buh a a,amTnibn and!or knadlgdlon, In my oprnlon d..W ocoor.d
al
the Iket data and place and der. to. EM aura(a) eta1Ad.
22a 1- OF DEATH 1 230. DATE STONED (Ma. DM, 11J
00/0 M
IS. MOTHER'S NAME
Cemetery
On Kemmerer, Wyoming 83101
PART 8. OTHER 810NIMCANT CONDITIONS•Cerdaipw cant/Wend Is death but not rela1W to caw. 44 .n In PART 1.
300. TIME OF
This is a true and exact reproduction of the document on file in the office of Vital
llt:%4y Records Services, Cheyenne, Wyoming
1 1SiP
lfir
30a. INJURY AT WORK?
(*WS yn of n)
Male
dc. UNDER 1 DAY
7o. CRY, TOWN. 011 LOCATION OF DEATH
23d. PRONOUNCED DEAD (Mo. Day. N.)
Kemmerer
10. SURVIVING SPOUSE (8 oil., gke martian none)
Alberta Frances Fern
909 Cedar Ave.
Find Mkda
Mary
1811 RELATIONSHIP TO DECEDENT
STATE FILE NUMBER
3. DATE OF DEATH (Ma. Day, o
September 12, 1999
11. DATE OF BIRTH (Mo., Day,
May 14, 1920
83101
September 13, 1999
Lucinda McCaffrey
Deputy State Registrar
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
7d. COUNTY OF DEATH
Lincoln
25b. DATE RECEIVED BY REGISTRAR (Afa, Day, M.)
30d. DESCRIBE HOW MARY OCCURRED
Malden Stamm.
Proust
20d. LOCATION CITY OR TOWN STATE
Kemmerer, Wyoming
b.4 21o. AOORE88 OF FACILITY
230 HOUR OF DEATH
23.. PRONOUNCED DEAD (Nov)
M
27. AUTOPSY (Spotty 28. 1•8 CASE REFERRED TO CORONER
yet cc no (Specify yee et no)
No No
301. LOCATION (Street and Number co Rod Rauh Number, City cc Town, 8Wa1
ANY ALTERA710N OR
ft
f i Mx'
o THIS CERTIFICATE r Da