Jene Marie GoodSTATE OF NEVADA - DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH - SECTION
VITAL STATISTICS
__1 BURIAL -TRANSIT PERMIT I
STATE FILE NUMBER
LUCAL HLt INUIVIUtn
DECEASED -NAME First Middle Last
DATE OF DEATHee.. (Month, Day, Year)
COUNTY OF DEATH
t. a`:.>s'�a is.''t:. s1v,1
2. n.£.a, ,c.`:.x p
3a.,�x.✓.t,e
CITY, TOWN OR LOCATION OF DEATH
HOSPITAL OR OTHER INSTITUTION -Name (if not either, give street and number) If
Rm.
Hosp. or Inst. indicate DOA, OP/Enver.
Inpatient (Specify)
SEX
3b. :'^. S
3c. ;.`. c «.< L.�C'% yt 'a'�,.l . ervictv..s 3e.
Inpatient
4. t e -
RACE -(e g., White, Black, American
Was Decedent of Hispanic Origin? Specify ❑ yes Ileo If yes,
AGE -Last
Birthday (Years)
UNDER 1 YEAR
UNDER 1 DAY
DATE OF BIRTH (Mo., Day, Yr.)
MOS DAYS
HOURS 'MINS
Indian, etc.) (Specify)
specify Mexican, Cuban, Puerto Rican, etc.
^...
a
8. AugustI 19246
5. s t .
6.
7a. a �
7b.
7c.
,
STATE OF BIRTH
CITIZEN OF WHAT COUN-
Decedent's Education. Specify highest
MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED
SURVIVING SPOUSE (If wife, give maiden name)
(If not U.S.A., name country)
TRY
grade completed. g
2
(sPecdy)
12.
9a. lows
9b. a, SA
USA
10. g,
.dowed
SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give Kind of Work Done During Most of KIND OF BUSINESS OR INDUSTRY
Working Life, Even if Retired)
13. 481-30-1387 e'r kk 14b. iP .l. t a:...
RESIDENCE -STATE COUNTY CITY, TOWN, OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
(Specify Yes or No)
z�:
N d 15c. 15d. 3101 1 .'s,-�2 .' a S t e 15e. :r. ~e S
FATHER -NAME First Middle Last
MOTHER -MAIDEN NAME First Middle Last
rd
16- e Edward
-,-'.:a�`..�. a.�=
INFORMANT -NAME (Type or Print)
MAILING ADDRESS (Street orR.F.D. No., City or Town, State, Zip)
` '
;rf
18b. .7-510 Cori sD-" Blair, -air, .���.`"t"> ka 68008
BURIAL, CREMATION, REMOVAL, OTHER (Specify)
CEMETERY OR CREMATORY -NAME LOCATION
City or Town State
19a. riQsea
9b. �€ie19c.
Blair, Nt,,bn!,4
FUNERAL DIRECTOR -SIGNATURE FUNERAL DIRECTOR NAME AND ADDRESS OF FACILITY Waiton Funeral Uozae
(Or Person Actmg.ag Suchf _ . LICENSE NUMBER „•.
"" -
20a.-... -'e 20b. 20c.75 3Wesa : . f.:n reef e`nc, i t >� ,0
I
Z 21 a. To the best of my knowledge, death ccurred at the time, date and place and 22a. On the basis of examination and/or investigation, in my opinion death occurred
at the time, date and place and due to the cause(s) and manner stated.
¢ due to the cause(s) stated.
o Fn (Signature and Title) (Signature and Title)
m= DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH d0 DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH
2
ao m
E
21 b. 21 c. 13135 c�io 22b. 22c.
tjz
a `
nLL NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print) tj PRONOUNCED DEAD (Mo.; Day, Yr.) PRONOUNCED DEAD (Hour)
I -M ~
U 21 d. 22d. ON 22e. AT
NAME A>q ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER). (Type or Print.)
LICENSE NUMBER
"11
23b.
23a. .- �i ' 1,36
REGISTRAR - -
DATE RECEIVED BY REGIST R (Mo., Day, Yr.)
DEATH DUE TO COMMUNICABLE DISEASE
24a. (Signature) ,(°'
24b. -
24c. YES❑ NOD
25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).) Interval between onset and death
PART (a) •
DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
(b)
DUE TO, OR AS A CONSEQUENCE OF: • Interval between onset and death
(c)
PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not resulting in the underlying cause given in Part 1. AUTOPSY Ves(SoreNt WAS CORONER CASE REFERREDTO
Specify s or No)
II 26. � sv 27 ,
AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
Having complied with all rules and regulations governing the preparation of dead human bodies and upon receiving the signatures of the person who is to certify the
cause of death, the funeral director or person acting as funeral director, and the local registrar, permission is granted to dispose of this body. The burial -transit permit
must be signed below by the cemetery or crematory authority. Where there is no full time person in charge of the cemetery the funeral director may sign as sexton.
Upon completion the permit mus ret rn d the local registrar where death occurred or to the funeral director.
� me�ery matory)
Signature of person in charge a� t Date
of the cemetery or crematory