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CERTIFICATION OF VITAL RECORD
VR 2 -89
8/97 15M
i :I+nlnul
I'1 ;Irl
l OF DEATH
o llc T `Ta or a1m TU.r.F'1' T R•r ata r^ r
1. DECEDEIIT•NAI FRET
520-44-9763
5 STATE OF BIRTH (2 not Jn USA,
171 RESIDENCE
J.. NAME AND ADDRESS OF CEt�11Flf�1
G. Christovher i T 11°
I51 REGISTRAR
2E. MANNER OF DEATH
LOCAL FEE NUMBER 1026
076756
C E T0(07773 A::CONSEQUENCE :OFI.
OATS Of INJURY
ITAWMA o•1; *A)
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
X49. TIMEOF
INJURY
LAST (::SEX 7. DATE.OF DEATH (Ma; Goy, W:.•
April 14. 1940
OF BUSINESS OR INDUSTRY
trical
STATE FEE NUMBER
r.;;`Wyoming.
30o. INJURY AT WORK? 704. DESCRIBE HOW INJURY OCCURRED
(Swett pa or no)
74. COUNTY OF DEATH
M•q•n &mow
Perkins
OR TOWN STATE
Wyoming
771 HOUR Of DEATH
27. AUTOPSY (S0•Wiy 28. WA5 CASE REFERRED TO CORONER
aw ar 60) (SP•ohr' (01 a 10)
No No,
27•. PRONOUNCED DEAD (Nov)
Tor. LOCAIiON (59.44.04 Maths or Puna Raul• Number. OBy Town, !MM
IDS THIS CERTIFICATE
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED:
Lucinda McCaffrey
Deputy State Registrar
This copy is not valid unless prepared on piper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.