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TYPE
OR PRINT
PERMANENT
BLACK
tat
FOR
INSTRUCTIONS
SEE
HANDBOOK
DECEDENT
NF HMANT
CAUSE
OF DE AEU
2 a FUNERAL
As Such
a. SOCIAL SECURITY NUMBER
520 -14 -2326
7. PLACE OF DEATH (Check only awl
H4e9CQ& I Qmg8:
yy na
Maed ER /Duaetad DOA
711. FACILITY NAME IN not kwfpei1M1 5404 eseet end IvMr)
TAR VALLEY HOSPITAL
8. SLATE OF BIRTH (I not H USA, nom coot" y)
WYOMING
12a. RESIDENCE STATE
WYOMING
13e. INSIDE CITY LIMITS?
(55.044 yes or no)
YES
17. FATHER'S NAME FM Middle LAM
LOUIS HALE
190 INFORMANT -NAME (Type w AMU
MARVEL HALE
190 MALLINO ADDRESS STREET OR F.D. R. NUMBER
87427 US -HIGHWAY 89
DISP GAT) N
22d. NAME OF AT7E
MMiEDIAT4 CAUSE (Firm
dames a cad0on
rotating in death) ea
SegwntW(y 1141 eordd41w.
I wry, leading b M medisM
aura Eder UNDERLYING
CAUSE (Masan or INuY
181 MOW* mental
naming in want LAST
29. MANNER OF DEATH
13b. COUNTY
LINCOLN
14. WAS DECEDENT OF HISPANIC ORIGIN?
(SMaly no or yea a meaty
Cuban. Marken. Puerto Phan, E(0)
la Yee (Specify)
UCE24EE Or Person Acting Number
DUE TO (O(( A CONSEQUENCE OF):
d.
H'Ypi TieaiCSata Ct*fie T a biMr +afaMe6i_ft O a: :came alma
DEPARTMENT OF HEALTH
3014 DATE OF INJURY
Month, Oar, Yowl
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
LAST
HALE
b. UNDER 1 YEAR
g WNRED. NEVER
WIDOWED. DIVORCED (S
MARRIED
13e. CRY TOWN OR LOCATION
AFTON
CRY OR TOWN STATE
AFTON WYOMING
200 CEMETERY OR CREMATORY -NAME
L NOVEMBER 30,1995 AFTON CEMETERY
21b. NAME OF FACILITY
22a. To the beet a( my IuNw(edge, maimed the tbr, deb and pace and due
b the cau1N0 Mama
(S(Otweae mid nal O
2214 GTE SIGNED (Lb. D. 220 HOUR OF DEATH
6:50 A
70 CITY, TOWN, OR LOCATION OF DEATH
AFTON
10. 8UNVNYq SPOUSE (d Who, 5744 nwlden nnr(
111. MOTHER'S NAME FYq
LOIS
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)(Typ. or PAWN
N HEAD, K PAUL MD 110 HOSPITAL LANE AFTON, WYOMING 83110
PART IL OTHER SIGNIFICANT CONO(ONB- Candnlone anbibuag m death but not nutted b cause given M PMT
2. SEX
MALE
MARVEL HALE MILLER
300 INJURY AT WORK?
(spec* As w no)
230 DATE SIGNED (Ma, Day. YW
23d. PRONOUNCED DEAD (MI, Dry, Yr.)
O45 K: S
72°
STATE FILE NUMBER
a DATE OF DEATH (A(0, Day, W.)
NOVEMBE -R 25, 1996
0. DATE OF BIRTH (Aka, Day, W.)
JULY 1, 1917
11. WAS DECEDENT EVER IN US. ARMED FORCES? (2a. USUAL OCCUPATION ((Mw kid of work Mae dtrkg n14 1 1211. KIND OF BUSINESS OR INDUSTRY
(Y -na/y ('fc or no) 01 wa*kg we, o.., 1 n4kod1
NO RANCH MANAGER I AGRICULTURE
130. STREET AND NUMBER
87427 US HIGHWAY 89
7d. COUNTY OF DEATH
LINCOLN
/E. DECEDENT'S Ea1Mw1PON
Woo* a 'W' MOAN Des. oonWN.d)
180. RELATIONSHIP TO DECEDENT
W•FE
210 ADDRESS OF FACIJTY
83110
0rWSCCArt.Fina beirM *FiMir Mir.bu:f*MM.M,•i: 44artB.NOreM.rea:aMfM':
Maiden Surname
ALLRED
20d. LOCATION CITY OR TOWN STATE
AFTON WYOMING
SCHWAB MORTUARY 45 44 EAST FOURTH AVE., AFTON
230 HOUR OF DEATH
23.. PRONOUNCED DEAD (Howl
2Sa. REGISTRAR n
(Srgrnree)
Cd ij aD L Enr the Obsesses. or conadbm that mused drain. Do not enter thtnade d dying, 414:1 maw 'Approximate
Masai Beeman
Ones( and Death.
27. AUTOPSY (SpeaA' 25. VMS CASE REFERRED TO CORONER
yes or no (Sp.rlty yes a. prof
NO NO
30d. DESCRIBE HOW PLAIN OCCURRED
307. 000A710 4 (SYeet end Number or Rural Route Number, City ce Town, atm.)
14849
4 tyi This is a true and exact reproduction of the document on file in the office of Vital rj y'
Records Services, Cheyenne, �Jf7 i �Jt
Il��r T'1 rr�,..,. j 1 1 v e
e DATE ISSUED: Lucinda McCaffrey \\LL
•pi Deputy State Registrar 1 t
This copy Is not valid unless prepared on paper with an engraved border disoia in_ the date, seal and Deputy signature of the De State Registrar. yA "III ��w�`
P.' P P P P g g Pty g I H=
114, ,4111
_4-CERTIFICATION OF VITAL RECORD
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