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FORMANT
IS)TifSN
(39 fll)
Tq(th tbbal ,ny knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated,
On the basis of examination and/or investigation. In my opinion, death occurred at the time
tf(s�11Se(e) Tnar)der as stated.
DATE Of INJURY
t6(fATION1
a DAT8 QP DISPOSITION
RACE Black, White, Am. Indian
(Tribe may be entered), Japanese,
etc. (Specify)
NF?RMANT
24'West. North, Plain City, Utah 84404
18. MAIDEN NAME OF MOTHER (First, Middle, Last)
Elva Jackson
EDUCATION (Specify only highest grade
completed) Elementary or Secondary
(012) College (13 -16 or 17
51. 11 motor vehicle accident specify If decedent was
driver, passenger or pedestrian.
i
P
4DlTt9F�lfl�a3
Rut 4 11Th
JF dNDER 1 YEAR
Month,'' Days
IF UNDER 24 HOURS
Hours I Minutes
e
resuiliiq in IAe
uoH evAla Kan%,
ertify that tfhli•)„
I 9rity of section;;
ate"Issued:
11
STATE OF UTAH DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
MIDDLE
(SKIN.
ATH 1 ri inyyene)
LAST
FOX
THEW, 9.1
Nursing Horne U 6 Residence 7. Other
fid C6UNTY OF DEATH
Weber
13b. CITY, TOWN OR COMMUNITY
Plain Cit 7
iECEDENT OF)- IISPANIC ORIGIN? r Ye L2. No
2, Guben. ):.J 3.Puerto Rican 4. Other (Specify)
19, 2000 Plain City Cemetery Plain City, Utah
23, LICENSEE NUMBER 24. FUNERAL HOME (Name. addles. and license number)
101186
101758 1 Leavitt's Mortuary
certified by medealexrndner, was death reported to M.E.? 1bs 1@2.Nol 836 36th Street
Yw and hourr °ported: M.E. Cam No. Ogden, Utah 84403
MO. DAY YEAR
5 ,CAUSE OF DEATH (ITEM 31) (TyperPrirrt)
475 S. 500 E., Ogden, Utah
IBS s '00 dbediI• SINAI CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC Appproximate Interval
OFI,REART FAILURE; LIST ONLY ONE CAUSE ON EACH LINE. I Deaatth een Onset and
4ONu
n.cu.L. d:riq Luro 5/ �s cI ri l�lOs�iu
1614.A£1 A CONSEQUENCE OF): l U
Gtt. 4tti d fka It ouu Te Art) �.e lr•!c{
04P (Qqt f(L I? NSEQUENCE OF
US TO OF):
y de thbiut not
n 1 1 'PaA 4
Dag Yr.)
2. SEX
Male
12a. DECEDENTS USUAL OCCUPATION (Give kind of work done
during most of working life. Do NOT use retired)
Brakeman
21b. PLACE OF DISPOSITION (Name of
cemetery, crematory, or other place)
35b. TIME OF INJURY
(24 Hour Clock)
STATE FILE NUMBER
3a. DATE OF DEATH (Mo. Day, Yr.)
May 15, 2000
late or Foreign Country)
644
3b. TIME OF DEATH (24hr.clock)
1150
7. SOCIAL SECURITY NUMBER
Wyoming 529 -30 -5824
8h. NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY (If outside a facility,
give sheet address of location)
4324 West 2650 North
9. SURVIVING SPOUSE (if oIle,give maiden name)
Jean L. Krell
30. COUNTY
27e, LICENSE NUMBER
/Po 9 S
12b. KIND OF BUSINESS OR INDUSTRY
Weber
21c. LOCATION City or Town, State
7d. DATE SIGNED (Mo., Day, Yr.)
30a. DATE REGISTRAR NOTIFIED OF DEATH (Mo.,Day,Yr.) 305. DATE FILED (Mo., Day, Yr)
MAY 182000
32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT l]
01. Probably contributed to the cause of death. 8 NOhL-U R
02)Nas the underlying cause of death. /er a sieS
Did not contribute to the cause of death. 6. UNKNOWN
4. Is unknown In relation to the cause of death. IF USER
35c. INJURY AT WORK?
1.Yes
2. No
33a. WAS AN 33b. WERE AUTOPSY
AUTOPSY FINDINGS AVAILABLE
PERFORMED? PRIOR TO COMPLETION
OF CAUSE OF DEATH?
0 1. Yes 02. NO ❑'(.Yes 0 2. No
35d. PLACE OF INJURY At home, farm, street, factory.
office, building,etc. Specfy)
g)Sq "HOW INJURY'OCCURRED (enter sequence of events which resulted in injury, NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31)
tWoefilficate on file in this office. This certified copy is issued
tah.de Annotated, 1953 As Amended.
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
II Jill III II U eyr-S
ii
DEPARTMENT OF HEALT
WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES.
1 ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION.