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DECEDENT
I. NAME OF DECEDENT FIRST MIDDLE UST
Newell Henry CROOK
2. SEX
Male
3a. DATE OF DEATH IMo. Day. Yr)
May 20, 1995
3b. TIME OF DEATH (24 is dodo
0545
s, DATE OF BIRTH (MO,. Day. wJ
Sept. 17 1914
5, AGE ytasr enndavl
80 vrs
IF uNDER 1 spin
it UNDER 24 HOURS
e. BIRTHPLACE /City Stan or Fwapn eouwvl
Freedom, Wyoming
7. SOCIAL SECURITY NUMBER
520 -09 -7451
Months Days
Hours xOT'
8e.. PLACE OF DEATH (Check oMy ens)
lib. NAME OF HOSPITAL. NURSING HOME OR OTHER FACILITY (a outside a lacddy.
give smog address of location)
South Valley Care Center
HOSPITAL:
Inpatient ER/Outpatient DOA
OTHER:
Nursing Home Residence Other
8c. CITY. TOWN OR LOCATION OF DEATH
West Jordan
8d. COUNTY OF DEATH
Salt Lake
9. SURVIVING SPOUSE (N wile. gale maiden name)
Mary Ellen Matthews
10. WAS DECEDENT
EVER IN U.S.
ARMED FORCES?
Iiil Yes No
11. MARITAL STATUS
Never Married Married
Divorced Widowed
(2a. DECEDENTS USUAL OCCUPATION (Give kind of work dons
during most of working life. Do NOT use retired)
Rancher
12b. KIND OF BUSINESS OR INDUSTRY
Dairy
(3e.. RESIDENCE STREET AND NUMBER
RFD
13b. CITY. TOWN, OR COMMUNITY
Etna
(3d. COUNTY
Lincoln
13d. STATE
Wyoming
(3s. INSIDE CITY
LIMITS?
LIMITS?
Y68 No
131. ZIP CODE
83118
f 1. WAS DECEDENT OF HI5PANIC ORIGiN7 ❑Vas No
(11 yea specify)
Mexican Cuban Puerto Rican Other (Speciivl
RACE
White
Am. Indian
entered)• Japanese.
18. EDUCATION (Specify only highest
Completed) Elements or Se gnu
10. (13.18 or 17 ry
14
PARENTS
17. FATHER'S NAM
William
(First: Middle, Last)
Henry Crook
18. MAIDEN NAME OF MOTHER (First Middle. Lan
Annie Evelyn Haderlie
INFORMANT
19. NAME. RELATIONSHIP AND MAILING ADDRESS OF INFORMANT
Fred A. Crook, Son, 9340 Betty Drive, West Jordan, Utah 84088
DISPOSITION
20. METHOD OF DISPOSITION [(0. DATE OF DISPOSITION
Entombment Donation Other
In Burial Cremation ❑Removal May 25, 1995
21b. PLACE OF DISPOSITION (Name or cemetery
crematory. or other place)
Freedom Cemetery
21e. LOCATION City or Town. State
Freedom, Wyoming
22.SIGNATURE OF FUNERAL SERVICE LICEN EE
I
23. LICENSEE NUMBER
115349
24. FUNERAL HOME (Name. add ass and license number)
Goff Mortuary, Inc'. 11101222
CERTIFIER
25. EDECEASED AS LAST
AMMO) 8y CERTIFYING PHYSICIAN
.5
28. II not certified by medical examiner. was death .ported to M.E.? Yes ONo
If yes, enter the date and hour reported: M.E. Case No.
8090 South State Street
Midvale, Utah 84047
HOUR W. DAY YEAR
27a. CERTIFIER
CERTIFYING PHYSICIAN
�o the best of my knowledge, death occurred at the lime. date, and place, and due to the cause(s) and manner as stated.
1,,.j(ait EXAMINER 1 AW ENFORCEMFNT OFFICIAL
4M.9 A e basis of examination and/or Investigation, in my opinion, death occurred at the time, date, place, and due to the cause(s) and manner as stated.
27b. S 4 1 TITLE OF ERTIFIER
27c. LICENSE NUMBER
g9($15g7-I
27d. DATE GD ;Day. Yr.)
NE
s z 'Fs
28 ma y% D0 ESS 0 R WHO CERTIFIED THE CAUSE OF DEATH (ITEM 31) (Type/print)
ndrew M. Heiner, M.D., 5770 South 250 East, Suite 445, Murray, Utah 84107
REGISTRAR
29. REGISTRAR'S NAT lE dVVWI 30.
10, --ewe f lsf tit
DATE FILED (Month. Day. Year)
May 22, 1995
CAUSE OF
DEATH
31. PART 1 ENT R TH DISEASE 1NJI .0; 'CAT NS THAT
OR RESPIRATORY ARREST. SHOCK. 9 H RE. LIST ONLY
IMMEDIATE CAUSE (Final a G
disease or condition 41
a
CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING. SUCH AS CARDIAC
ONE CAUSE ON EACH LINE.
t
Approximete Interval
Between Onset And
Death.
resulting In deafly DUE (OR AS A CONSEOUENCE OFI:
Sequentially list conditions. 5.
If any, leading to Immediate DUE TO /OR AS A CONSEOUENCE 07):
cause. Enter UNDERLYING
CAUSE (disease or injury a
Initiated
that events resulting DUE TO ion AS A CONSEQUENCE OF)
in death) LAST
e.
I-
PART II. Other Significant Conditions contributing o death but not
resulting M the underlying cause given In Pant
rs•��
32. IN YOUR OPINION. TOBACCO USE BY THE DECEDENT
0 P obably contributed to the cause of death
0 Was the underlying cause of death
rIs DM not contribute to the cause of death 0 N
unknown In relation to the cause of death NON-USER
33a. WAS AN
AUTOPSY
PERFORMED?
I Yes No
33b. WERE AUTOPSY
FINDINGS AVAILABLE
PRIOR TO COMPLETION
OF CAUSE OF DEATH?
Yes No
34. MANNER OF DEATH
Natural Accident
0 Suicide Homicide
Undetermined Pending
If Inured Investigation
Purposely or
Accidentally
35a. DATE OF INJURY
(Month. Day. Year)
35b. TIME OF INJURY
I (24 Hour Clock)
35e. INJURY AT WORK?
f-f
I 1 Yes No
35d. PLACE OF INJURY -A tome. farm, street. factory.
office. building. ate. (Speedy)
35e.LOCATION (Street or rural route number. city or town. county and state)
35g. If motor vehicle accident. sootily if decedent was
driver• passenger or pedestrian,
351. DESCRIBE HOW INJURY OCCURRED (enter sequence of events
which resulted in injury, NATURE OF INJURY 51401)1080 EB�N ITEM
aA�1
Th WARNING: IT IS ILLEGAL TO DUPLI( IIS COPY FOR OFFICIAL PURPOSES.
ao teSoYasearro3° cado' r t
Amass w seormaaon on
Vas fain a 114014 under
0. Vial Swann M
one Rubs LOCAL FILE NUMBER
i s is to certify that this is a true copy of the
information on file in this office.• This certified
copy is issued under authority of Section 26-15-26
of the Utah Code Annotated, 1953 as amended.
Date Issued
SALT LAKE CITY COUNTY HEALTH DEPARTMENT
DIVISION OF VITAL STATISTICS 4 0 3
18-
160383 MAY 221995
STATE OF UTAH DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
www�
Thomas L. Vchletiker, MD
Director of Health
TATS F
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