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TYPE
OR PRINT
PERMANENT
BLACK
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
(If fi MAT)?
CAUSE
OF DEATH
1. DECEDENT -NAME FIRST
DONALD
2
4. SOCIAL SECURITY NUMBER
572 -34 -6577
7a. PLACE OF DEATH (Check only one)
t14Sffid6� IQTg
7b. FACILITY NAME (I not Institution, glue sewn and number)
8. STATE OF BIRTH (ti not N USA., name cowary)
MINNESOTA
11. WAS DECEDENT EVER IN U.S. ARMED FORCES?
(Spotty Res or no)
YES
13.. RESIDENCE STATE
WYOMING
13a INSIDE CITY UNITS?
(Spedly y.. or no)
17. FATHER'S NAME Flat
DAVID
1 ga. INFORMANT -NAME (T,y. or Rio)
180. MAILING AODRE8S STREET OR R.F.O. NUMBER
P. 0. BOX 476
20a. Buria4 Cremation, Removal
Iron* State, Other (Spoon?)
C
E
(CAL FILE NUMBER
inpatient ER /Outpatient DOA
659 ALTA DRIVE (STAR VALLEY RANCH)
NO
Sequentially 1St condition.,
it ark. NNE% 10 Immediate
cause. Enter UNDERLYING
CAUSE (Disease or WwY
net Initialed *wants
mWang in deem) LAST
28. MANNER OF DEATH
twat �ineel 4400
J V
accident
VR 2 -89 E'0dde [kid nol be
Determined
4/94 15M N Honied.
13b. COUNTY
LINCOLN
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Specify no or yes II yea apeolly
Coban, Mexican, Pua(0 Rican, Etc)
LORRAINE KITTLESON HOOVER
20b. DATE (Ate., Day, W.)
N JANUARY 13,1996
CENSEPpr Perron Acting Number
22e. To ben a my know
ate Carr.).) staled.
(5)preen and Thiel
2210 DATE SIGNED (M0
Y.
W.)
°Ccur
5.. AOE -Last Bklhday
(Yew.) 64
Y.. (Speclryl
ATddie LAM
HOOVER
41.J IQQ, 12:10 a. M
220. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONERI(7ylm w Print)
MIDDLE LAST
WILLIAM HOOVER
farming Hon set Rei denos Other (Specify)
0. D. PERKES MD. 110 HOSPITAL LANE AFTON, WYOMING 83110
25a. REGISTRAR a ff s
(Signora)
PAM I. Enter the disease., 'Nunes, complications 641 caused death. Do not antra the mode of dying. such as cardiac
26
or r0Naraory alma, Mack, or heart Wien. UM only one cause on each line.
IMMEDIATE CAUSE (Final
disease or cmdilk 0
mailing In deem) 0
DUES '10 (OR A 1:
A COONSEOUENC
b`L� du /-1 &At- cid -a-5 S .-7v se cce_e.J
E TO (OR AS A CONSEQUENCE OF):
Date Issued
DUE TO (OR AS A CONSEOUENCE OF):
PART I. OTHER SIGNIFIC14T CONDITIONS- Conditions conkl5utkq b death but not related to eau.. given In PART I.
30a. DATE OF INJURY
(Month, Day, yawl
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
58. UNDER 1 YEAR
Months Days
9. MARRIED, NEVER MARRIED.
WIDOWER DIVORCED (Spao(
MARRIED
13c. CITY. TOWN OR LOCATION
THAYNE
CITY OR TOWN
THAYNE
20e. CEMETERY OR CREMATORY -NAME
7e. CITY. TOWN. OR LOCATION OF DEATH
THAYNE
12a. USUAL OCCUPATION (OMa kind of work done dw:ny moat
04 working 81e, ev.n 6 raked)
TEACHER /COACH
15. RACE American Indian,
Black, White, Etc.
(SPeody)
WHITE
18. MOTHER'S NAME First
MARY
HILL SANBERG CREMATORY
21b. NAME OF FACIUTY
SCHWAB MORTUARY
tea and clue
22c. HOUR OF DEATH
M I
30a. PLACE OF INJURY -AI hone. fun, street, factory,
office building. etc. (Sp./1y)
30b. TIME OF *30c. INJURY AT WORK?
INJURY (Spaclly yes or net)
08C
2. SEX
MALE
UND R 1 DAY
Minute.
10. SURVIVING SOUSE (ti WM, glwa maids rune)
LORRAINE KITTLESON
STATE
WYOMING
S 23d. PRONOUNCED DEAD (Ala, Day, riJ
STATE FILE NUMBER
3. DATE OF DEATH (Ala, Day, W.)
JANUARY 13, 1996
6. DATE OF BIRTH (Ma, Day, Yr.)
MARCH 20, 1931
12b. KIND OF BUSINESS OR INDUSTRY
EDUCATION
13d. STREET AND NUMBER
659 ALTA DRIVE (STAR VALLEY RANCH)
16. DECEDENT'S EDUCATION
(4.00)y only highest grade oompMMd)
Elemontary /2•ordary (0 -12) College (1- 4 Of 5*)
18b. RELATIONSHIP TO DECEDENT
WIFE
7d. COUNTY OF DEATH
LINCOLN
Middle Malden Surname
LEMBRIGHT
21P CODE
83127
BLACKFOOT, IDAHO
Number 210. ADDRESS OF FACILITY
45 44 E. FOURTH AVENUE
examination /a kNSS'
23a. On Iha b..le d tg.lion, In my opinion death occurred
at the the, date and pace and due to the caue.)0l Naiad.
MEM. and 011e) I►
100 23b DATE SIGNED (Ma, Day, Yr.)
23c. HOUR OF DEATH
25b. DATE RECEIVED BY REGISTRAR (Ala, Day,
FEB 1 1996
Z/
Deputy State Registrar
12 5 PLUS
20d. LOCATION CITY OR TOWN STATE
23e. PRONOUNCED DEAD (Nora)
M
IAppm0Mate
Ihwval BNween
and Death.
ILL.-(
1
27. AUTOPSY (Spaty 28. MS CASE REFERRED TO CORONER
yea a not (Speody As or nU)
NO
NO
30d. DESCRIBE HOW INJURY OCCURRED
M
301. LOCATION (Seel and Number or Rural Rana Number, City or Town, State)
THIS IS TO CERTIFY that this reproduction is a true copy
of a record on file in Wyoming Vital Records Services,
Cheyenne, Wyoming.
This copy is not valid unless it bears a raised seal and the
signature of the Deputy State Registrar is in red.