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NMOWNII dO A.NfOD 3111
'SS
ONIWOAM dO 31d1S 3H1
0',.i.`°
State of Wy9rping
County of xoo�
The foregoing instrument was acknowledged before me by Jeanette
Marie Hacklin this :1‘g day of fY1taA 2_0c a
Witness my hand and official seal.
KIM GUNriJ RMAN NOTARY PUBI C
County of
ate of
Crook "k,,17 WPM*
<cav�
My Commission Expires
My Com i I
4l .c��
(Th
7 7 5
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Notary Public
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CERTIFICATION OF VITAL RECORD.
t?:J: a: a• 41: a: 4: 1: tel: a: isa: l: l: a} :a:1¢:a:a:41:1:a:4:a:a:a:aa:a:a a:Ia a a •a •s •t •l fat t •a s a •t •f •tss a •a a •a •s a •r •14 a a s •a •a •a a.a.a:t t a a a t i t t s 4 i s a t s a a a f*4: 4 1414:4Y,Ja;J
4 PP 1. DECEDENT -NAME FIRST
TYPE
DR
PERMANENT
BLACK
21( 4. SOCIAL SECURITY NUMBER
INSTRUCTIONS 520 -07 -3459
SEE
NANDB00K
MOM
70. PLACE OF DEATH (Deck on)y one)
8. STATE OF BIRTH (I not 41 USA., nm. 0oU*y)
11. MKS DECEDENT EVER IN U.S ARMED FORCES?
(Speo:ry yes or not
Wyoming
No
13a. RESIDENCE STATE
Yes
LOCAL FILE NUMBER
Wyoming
(3s. INSIDE CRY MOTS?
(SPeo(h yes or. not
Geor>;e
17. FA14484 8 NAME Fk11
Thomas
t8a. INFORMANT -NAME (T,P• der
24. NAME AND ADDRESS OF CERTIFIER ?PHYSICIAN
Ronald D. Glas, M.
26a. REGISTRAR
(SIVWe)
PAM 1. Enter IM diametral, (44wle
28. at nepireto.y arrest,
IMMEDIATE CAUSE (Final
disea4 or condition
resulting In death) 4
Sequentially Ile! condition,
M any, leading to Immediate
cause. Enter UNDERLYING
CAUSE (Disease er Intury
that initiated er.ma
mulling In death) LAST
STATE OF WYOMING
02196
Inpatient O ER /Outpatient O DOA I MEa aNW!'* la Home 0 Reaerwe mar (44.0((7)
7b. FACILITY NAME (!r not N4OEUrbn, glee slier and iuobe1)
Retirement Center of Sublette County
13b. COUNTY 13c CITY TOWN OR LOCATION
Sublette Pinedale
14. vas y roaw IYaa..� o e4yr
Cubes, M449art, Puarte Rkw, Eta)
No et Y05 Q r 6�Ei# 1
MIDDLE
Earl
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
6a AGE-last Bk8dey
(Vert)
84
LAST
Yeoman
66. UNDER '1 YEAR
money) D.
9. WARIER NEVER MARRIED
WIDOWED DREADED isivat
Widowed
12a. USUAL OCCUR1f0N (bra *bard car a9dr 404 duke
d Rokhp Nee eve 8 r.Mnd)
Oilfield "Worker
Yeamarx Jr.
Bunny Hacklin
10c. MAILING ADDRESS STREET OR R.F.D. NURSER CITY OR TOWN r STATE'
5 Eaat Sage Street, Pine Haven .Wyoming ,82721
20a. Burial, Cremation, Renaval 206. DATE(Mo., Dy,. N.) 20e. CEMETERY`04 CREMATORY -NAME
Dom State, Other (Specify)
Removal Aug. L. 1996 Viola Cemetery.
21.. FU RAL SERVICE UCENSEE Or Penrl Acting Number 21b. NAME OF FACILITY
4 (6
1 j 72 Hudson's Nhneral Hane
1Ni= ORMA 1.11
01 .I CSITION
CAUSI
Of DE- AT II
44 the crs.(e *fated
(Signature end 7NN)
22b. DATE SHINED (MID., Yr.) 2 24 HOUR OF DEATH
August 12, 1996 12:40 PM
22d. NAME OF ATTENDING PHYSICIAN IF OTHER, THAN CERTIFIER 11791 ar PM()
a
w tnu oboe a pyfng a d1 ea caroled
n UN only we mum an each Mme'.
Nn24&2.4o(e4e_ A(f I-- eteR1446 -E_
DUE TO (OR AS A CONSEQUENCE OF):
TALL
DUE TO (OR AB A CONSEQUENCE OF):
'?AR 6GVA1
DUE TO (OR AS A CONSEQUENCE Of):
d.
PART I. OTHER SIGNIFICANT 00404 IONS- Donators contributing 4, dsaa but not Mated lo aauea given In PAM
A ~75
N� 29. MANNER OF DEATH
N, Nelvel g (o R6
J T''' A4ceent
Q VR 2 -89 Biacids
4/94 15M
06583
Pending
'Could not be
Determined
30e. DATE CIF INJURY
(Mona, Day, Mar)
300. TIME OF
INJURY
30e. PLACE OF INJURY -At home, IYw drag. factory.
ottir itAdlad, are. r
KrSINt r &NAG
Hour
1 e:'mOtHEa•S:NAME
304: INMIRY AT WORK?
(Specify yes et no)
j LIE
2. SE%
Male
6c. (RIDER 1 DAY
7c. 4TY. IoM(, OR LOCATION OF DEATH
Pinedale
10'- 8URVNIRG SPOUSE (6 ANA give 'Wean name)
16. RACEAmadcen IMlen,
Bleck W EN.
White
M
19d. STREET AND NUTABER'
Ethel
236 DATE IRONED (Ma Or()! Md
August 1 2 1996.
23d: lino. Day, Yr)
st 11 1996
STATE FIDE NUMBER
9. DATE OF DEATH (Ma, Day, 11:1
August 11, 1996
8. DATE OF BIRTH (Ma, Dry, Yr.)
June 5, 1912
*2 5 .:KIND OF BUSINESS OR INDUSTRY
Petroleum
19b. RELATIONSHIP TO DECEDENT'
Dauthter
DP 0000
70. COUNTY OF DEATH
333 North :Bridger Avenue
18
DECEDENT'S EDUCATION
apology only (*IIeg tarts competed)
ted)
Elementary /SecoderY (0 -021 College (1 -4 or 84)
8
200. LOCATION CITY. OR TOWN
Number 21e. ADDRESS OF FACILITY
115 164N.Brid:
M tin INS and p4caand the L y ��jin
(fin are TN.)
LaBarge, Wyoming
CORONERI(rype 02 n/aa)
Pte.. Bob 627, 619 East Hennick, Pinedale, Wyoming 82941
26b:: DATE RECEIVED BY REGISTRAR (Ma, Day, TM
August 12, 1996
300. DESCRIBE HOW INJURY OCCURRED
Lucinda McCaffrey
Deputy State Registrar
e This copy Is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
Sublette
Su
W rrurn
Brown
er Pinedale WY
Coroner
23c. 23c OF DEATH
12:40 P
23e. PRONOUNCED DEAD( Nor)
12:40 P m
7 l F2Pf� )(AZ f
STATE
l«,
k,
Onset end Death.
18 k
27. AUTOPSY (Speedy 28. WAS CASE REFERRED TO CORONER
ea
yeaer ed (Speer Y or no)
No Yes
301. LOCATION (Street and Number or RW4I Route Number. City at Town. Stele)
3 8m ear, Piv► eca1e, 1 44'
777
1
lit
This is a true and exact reproduction of the document on file in the office of Vital
C Records Services, Cheyenne, Wyoming
?pp DATE ISSUED: P ri t i z
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ANY ALTERATION OR E
Tf:attifaaaatt tit 1•ittttt t tibltttlttt•a•a
OIDS THIS CERTIFICATES