Marjory DoresCONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
-
STATE OF NEVADA - DEPARTM' NT OF HUMAN RESOURCES
DIVISION OF HEALTH - SECT' N OF VITAL STATISTICS
BIT T tN IT PERMIT
1 Or.Al FII r NI IPARFR CTATF FII F NI IMRFR
DECEASED -NAME First
Middle Last DATE
OF DEATH (Month, Day, Year)
COUNTY OF DEATH
��r
-:^`-vss.-; aM+
.,.,*s..-�:.xv; *`�- _ 2.
,Y.
3a.Clark
CITY, TOWN OR LOCATION OF DEATH
HOSPITAL OR OTHER INSTITUTION -Name (If eit -, give street and number)
If Hosp. or Inst. indicate DOA, OP/Emer.
SEX
t�- „i,3. =,.=m r" ..�...a
-_ _
?-�€a-:.. ', ori-: ���co�„".�-{...�.���
Rm. Inpatient (Specify)
�,�_�: t!Ea£,
4.
3b.
3c. <?l5r:t, rac'l
3e.
�°�., sm.!k.
RACE-(e.g., White, Black, American
Was Decedent of Hispanic Origin? Specify ❑ yes Ino If yes,.
AGE-L;st
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.
BirthdayyYears)
5 .e«w
6.
7a.$
7b.
7c. 8'
STATE OF BIRTH
CITIZEN OF WHAT COUN-
Decedent's Education. Specify highest
MARRIED, NEVER MARRIED,
SURVIVING SPOUSE (If wife, give maiden name)
(If not U.S.A., name. country)
TRY
grade completed.
WIDOWED, DIVORCED
9a. -;•?•:„
9b.``:,
10.
(Specify) sa,.d.€*z..+:
12.
SOCIAL SECURITY NUMBER
USUAL OCCUPATION (Give Kind of Work Done During Most of
KIND OF BUSINESS OR INDUSTRY
Working Life, Even If Retired)
"''c�..f*,.c3»t :
13.
14a ..=z ._`,
14b f-ojigT y
RESIDENCE -STATE
COUNTY
CITY, TOWN, OR LOCATION
STREET AND NUMBER
INSIDE CITY LIMITS
�. . -s�€°
15a.
15b.
�.,.-.°."''''
> �.. "'i T$.
15c. --a "-'-.... a..',
€ a -w:. :~:'
15d. �.k ,. .M«-s.,�:.:* .,'m`_;ew
(Specify Yes or No)
15e.
FATHER -NAME First
Middle Last
MOTHER -MAIDEN NAME First Middle Last
16. aate
17.
INFORMANT -NAME (Type or Print)
MAILING ADDRESS (Street or R.F.D. No., City or Town, State, Zip)
" >r"."_
� 3ti`�_..=,.f
r s: �s r' .-,.,. n. z"- "'.:re.„3:..'' a.,,:.
'� __ r. •,.x.�-T
16a. T
18b. �
BURIAL, CREMATION, REMOVAL, OTHER (Specify)
CEMETERY OR CREMATORY -NAME
LOCATION City or Town State
r" ,.-..�, r
,
'" ;af*'.; ��o t'It y -...n ��„,+
",�' i s.y z�-
19a
19b. ate, ,�s�t�T`
-
19c. , =
FUNERAL DIRECTOR -SIGNATURE
FUNERAL DIRECTOR
NAME AND ADDRESS OF FACILITY
(Or Person Acting as Such)
20a. - -
LICENSE NUMBER
20b. -514
20c. 3331r i«m 3' iIrT!VS- �0
Z 21 a. To the best of my knowledge, death occurred at the time, date and place and
22a. On the basis of examination and/or investigation, in my opinion death occurred
a due to the cause(s) stated.
at the time, date and place and due to the cause(s) and manner stated.
�} (Signature and Title)
(Signature and Title)
tz:DATE SIGNED (Mo., Day, Yr.)
a
HOUR OF DEATH
RE
20 DATE SIGNED (Mo., Day, Yr.)
an
HOUR OF DEATH
0Y 21 b.
21c.
m o 22b.
22c.
I F NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (7ype or Print)
oP
'atj PRONOUNCED DEAD (Mo., Day, Yr.)
PRONOUNCED DEAD (Hour)
w
U 21 d.
22d. ON
22e. AT
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER). (Type or Print.)
LICENSE NUMBER
REGISTRAR
DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)DEATH DUE TO COMMUNICABLE DISEASE
24a. (Signature)
24b. 24c. YES[] NO FJ,'
25. IMMEDIATE CAUSE (ENTE7 O ME A S INE R (-a=T (c).) Interval between onset and death
PART (a)
I 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 (Specify WAS
CASE REFERRED TO
II
Yes or No) CORONER
(Specify Yes or No)
-
26. t,..-.� 27.xa
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 must be returned to the local fegistrar where death fpccurred or to the funeral director.
Signature of person in charge
of the cemetery or crematory
% 232700
yry
Date f Le' -- 2 LG -3
EfURiAL FE Ni f