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19 COMMUNITY ,p ii"Arale
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2. SEX 3a. DATE OF DEATH (MO. Day, Yr)
male Feb. 15, 1997
6. BIRTHPLACE (Gaya Stale or Farrago Cooney)
Centerville, Utah
21b'„ ACE OF DISPOSITION (Name or
4n904. Crematory or other place)
nterville Cemetery
//#'//";/e
r7 S.US&J&L000UPATION (Give kind of work done
gl
91 Dq NOT use refired)
e /Porter- Walton Co.
1 0)00r(Specif
Mar
'Cehtery lle
NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY (11 outside a leaky.
give street address of location)
9. SURVIVING SPOUSE (a+SM.aiw maiden name)
Ruth Hyde
5. RACE Black. White, Am. Indian
(Tribe may be entered). Japanese.
etc. (Spec/)
18: Bountiful, Utah 84010
3 0a, `DATE REGISTRAR NOTIFIED OF DEATH (Mo..Day.Yr.
DR OPINION; TOBACCO USE BY THE DECE ENT
9 4y cgntribuled to the cause of death. SER
(4 LIM undgrlying cause of death.
�p1 fig odb(tg to the cause of death.
.Ndk�(W vn In r,(dtion to the cause of death
EY�r% OF INJURY 15c. INJURY
White
Lawn and Garden
Wholesale Distribution,
pEATN: DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC
QN;ACH LINE.
TIME OF DEATH (24hr.clock)
13:50
EDUCATION Specily only htlbeal grade
completed) Elementary or Secondary
(0 -12) College (13 -18 or 174-)
address and license number)
68 Russon Brothers Mortuary
295 North Main
Bountiful, Utah 84010
'(1al'the time, dale. and place, and due to the cause(s) and manner as slated.
examination and /or investigation, In my opinion, death occurred at the time,
)b. DATE FILED (MO.. Day, Yr.)
Februar 25 1997
Appprroeimate Interval
De ath Ontel end
Death 7
e
33b. WERE AUTOPSY
FINDINGS AVAILABLE
PRIOR TO COMPLETION
OF CAUSE OF DEATIIT
1. Yes 02. No
35d. PLACE OF INJURY At home. )arm, street, factory.
office, buildina,etc. (Spas/"),)
351. 11 motor vehicle accident specify i1 decedent was
driver, passenger or pedestrian.
EPARTM,F,NT OF HEALTH
E OF DEATH
titer ifquer,cp of events which resulted in injury, NATURE OF INJURY SHOULD BE
this office. This certified copy is issued
95$ `As Amended.
WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES.
Y ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. ""f",