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TYPE
oRIN
PERMANENT
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
DECEDENT
1. DECEDENT -NAME FIRST MIDDLE LAST
MARILYN EDITH DALEY
2. SEX
FEMALE
3. DATE OF DEATH I Mo., Day, W.)
JUNE 20, 1995
e, SOCIAL SECURITY NUMBER
446-36-4058
5a. AGE -Last Birthday
(years)
57
5b. UNDER 1 YEAR
5c. UNDER
1 DAY
6. DATE OF BIRTH (Mo., Day, Tr.)
JANUARY 17 1938
y
Months
Days
Hours
h9rNll
70. PLACE OF DEATH (Check only one)
j
Inpatient O ER /OUtp01ien1 DOA 8r O Nurain9 Home O Residence O Other (Speedy)
70. FACIUTY NAME (6 not ins0lu(km, give 01,86 and ruanb01
STAR VALLEY HOSPITAL
7c. CITY, TOWN. OR LOCATION OF DEATH
AFTON
7d. COUNTY OF DEATH
LINCOLN
8. STATE OF BIRTH II/ not h U.S.A., name coley)
OKLAHOMA
9. MARRIED, NEVER M C ARRIED,
W iM N
10. SURVIVING SPOUSE (0 wile, give maiden name)
WILLIAM L. DALEY
11. WAS DECEDENT EVER W US. ARMED FORCES?
(Speedy yes Of no) NO
120. USUAL OCCUPATION d i mrl C N, work doneduring most
SELF EMPLOYED
126. 6190 OF BUSINESS OR INDUSTRY
CONSTRUCTION
130. RESIDENCE STATE
WYOMING
130. COUNTY
LINCOLN
13c. CITY, TOWN OR LOCATION
THAYNE
13d. STREET AND NUMBER
936 VISTA WEST DR.
13e. INSIDE CITY LIMITS?
(Spicily yes or no)
NO
14. WAS DECEDENT OF
(Specify no or yes
HISPANIC ORIGIN?
it yes, specify
16. Black, RA CE �e Indian
E
fy W
WHITE
Le. DECEDENT'S EDUCATION
(Specify only NOW grade completed)
Cuban. Mexican, Puerto Rican, Etc.) NO
No O Yes O (Specl(y)
Elementary/Secondary (0 -12)
12
College (1 or 5
2
17. FATHER'S NAME Find Middle Last
PARENTS MARION F HOPKINS
18. MOTHER'S NAME Fist Middle Malden Surname
MARY LOUISE. WILLIAMS
180. INFORMANT -NAME (Type a Print)
WILLIAM L. DALEY
190. RELATIONSHIP TO DECEDENT
SPOUSE
far l7AMA NT
/9t MAILING ADDRESS STREET OR RF. °.NUMBER CI re OR TOWN STATE 21P 00110
P. 0. BOX 664 THAYNE WYOMING 83127
200. Burial, Cremation, Removal
Irora Sate, Other (Specify)
BURIAL
20b. DATE (Ma., Day, Vr.)
JUNE 23, 1995
20c. CEMETERY OR CREMATORY -NAME
THAYNE CEMETERY
20d. LOCATION CITY OR TOWN STATE
THAYNE WYOMING
DISPOSITION
21. FUNERAL LIG Per Acting Number 210. NAME OF FACILITY Number
II. 426 SCHWAB MORTUARY 45
�i Lid
21c. ADDRESS OF FACILITY
44 E 4TH AVE, AFTON,WYOMING
�r
a. 0 6N a my nowledge, deaN occurred the date and place and due
to the cause(*) Naiad.
7(00)
23a. On 00 time, d d a exa examination and/or due investigation, my opinion death occurred
at
B Sgnan r and 1)00)
/Signature and
221. DATE SIGNED (Mo., Day, yr 1
1 rr G b 2 2- q
22c. HOUR OF DEATH
3. 3
5 230. DATE SIGNED (Ma, Day, WJ
o
23c. HOUR OF DEATH
M
CERTIFIER
22d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
W
.8 g 23d. PRONOUNCED DEAD (Mo., Day, 71)
23e. PRONOUNCED DEAD (How)
M
J
11
CAUSE
OF DEATH
(JS6641:413i
2e. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)(TW. a NM)
NOEL STIBOR MD. 110 HOSPITAL LANE AFTON, WYOMING 83110
250. REGISTRAR
(Samba.)
2 PART 1. Enter the diseases. Injuries. or inking that caused death. Do not enter the mode of dying, such as cardiac
e. or reapu0lay arrest, slack, or heart (allure. UM only one 90000 00 each WV.
IMMEDIATE CAUSE (F(n.I
disease or condition
resulting in death) a f i t /err V* 1 y 41✓f
DUE TO )00R AS A C ONSEQUENCE OF):
Sequentially tat conditions, DUE TO (OR AS A CONSEQUENCE ®F):
Y any, Nadine to immediate J
cause. Enter UNDERLYING g a Many (Disease ury DUE TO (OR AS A CONSEQUENCE OF):
1h61 initiated event.
resulting In death) LAST d
PARR 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not related (0 cause given In PART I.
29. MANNER OF DEATH
Natural ElTbMing
Investigation
Suicide Q kaki not be
Oetermined
Accident
VR 2 -89
2/91 15M NN tbmicda
Date Issued
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
300. DATE OF INJURY
(Month, Day, Year)
300. PLACE OF INJURY -A( home. farm. etre0, lectern,
ollice building, etc. (Spocdy
JUN 2 7 1995
300. TIME OF 30c. INJURY AT WORK?
INJURY (Sp0 JIy Ws or no)
265. DATE RECEIVED BV REGISTRAR (Ma, Day, m)
27. AUTOPSY (Specify
yes or 00
NO
STATE FILE NUMBER
30d. DESCRIBE HOW INJURY OCCURRED
206
Approximate
'Interval Between
I OnNI and Death.
28. WAS CASE REFERRED TO CORONER
(Specify yes or no)
NO
301. LOCATION (Street and Number or Rural Route Number, City a Town. Slate)
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