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REGISTRAR
<br />24a. (Signature)
<br />, % d. A, ,
<br />►, �►, ♦ J,411. ,
<br />'4111,4:
<br />DATE RECEIVED BY REGISTRAR � ( / Mo. , Yr.)
<br />4b. I /1111 /
<br />DEATH DUE TO COMMUNICABLE DISEASE
<br />24c. YES El NO'
<br />DISPOSITION
<br />CERTIFIER
<br />DECEASED -NAME First Middle
<br />1. Robert L
<br />CITY, TOWN OR LOCATION OF DEATH
<br />3b. Boulder City
<br />RACE- (e.0., White, Black, American
<br />Indian, etc.) (Specify)
<br />5. White
<br />STATE OF BIRTH
<br />(If not U.S.A., name country)
<br />ga. Nebraska
<br />SOCIAL SECURITY NUMBER
<br />13. 505 -42 -5152
<br />RESIDENCE -STATE
<br />15a. Nevada
<br />FATHER -NAME First
<br />16. Alva
<br />BURIAL, CREMATION, REMOVAL, OTHER (Specify)
<br />19a. Cremation
<br />HOSPITAL OR OTHER INSTITUTION -Name (II not either, give street and number)
<br />Sc. 504 Pacifica Way
<br />Was Decedent of Hispanic Origin? Specify ❑ yes gl no If yes,
<br />specify Mexican, Cuban, Puerto Rican, etc.
<br />6.
<br />CITIZEN OF WHAT COUN-
<br />TRY
<br />Sb. USA
<br />USUAL OCCUPATION (Give Kind of Work Done During Most of
<br />Working Life, Even if Retired)
<br />14a. Sales
<br />COUNTY
<br />15b. Clark
<br />Middle Last
<br />Loewenstein
<br />INFORMANT -NAME (Type or Print)
<br />18a. Marjorie Loewenstein
<br />FUNERAL DIRECTOR - SIGNATURE
<br />(Or Pe
<br />2ba. °' 7 S
<br />•
<br />Z 21a. To the best of ae cno ated. - , death occurred at� y � fine
<br />So
<br />due to the ca se )stated.
<br />v} (Signature and e) 0
<br />o 2
<br />ao.
<br />Etry
<br />0
<br />O
<br />-g
<br />oir
<br />in
<br />0
<br />FUNERAL DIRECTOR
<br />LICENSE NUMBER
<br />20b. 15
<br />LOEWENSTEIN
<br />DATE SIGNED (Mo., Day, Yr.)
<br />21b.
<br />NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
<br />21d.
<br />Last
<br />AGE -Last
<br />Birthday (Years)
<br />7a. 76
<br />Decedent's Education. Specify highest
<br />grade completed. 12
<br />10.
<br />CITY, TOWN, OR LOCATION
<br />15c. Boulder City
<br />UNDER 1 YEAR
<br />MOS • DAYS
<br />7b.
<br />CEMETERY OR CREMATORY-NAME
<br />19b. Rites Crematory
<br />DATE OF DEATH (Month, Day, Year)
<br />2. December 13 2002
<br />If Hosp. or Inst. indicate DOA, OP /Emer.
<br />Rm. Inpatient (Specify)
<br />3e.
<br />UNDER 1 DAY
<br />HOURS • MINS
<br />7c.
<br />•
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED
<br />(Spedly) Married
<br />STREET AND NUMBER 50 4
<br />15d. Pacifica Way
<br />COUNTY OF DEATH
<br />3a. Clark
<br />SEX
<br />4. Male
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />e. Oct 1 1926
<br />SURVIVING SPOUSE (If wile, give maiden name)
<br />12. Marjorie Wechsler
<br />KIND OF BUSINESS OR INDUSTRY
<br />14b. Recreational Vehicles
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />15e. Yes
<br />MOTHER - MAIDEN NAME First
<br />Middle Last
<br />17. Opal Storer
<br />MAILING ADDRESS
<br />(Street or R.F.D. No., City or Town, State, Zip)
<br />1131 504 Pacifica Way Boulder City NV 89005
<br />LOCATION City or Town State
<br />19c. Henderson Nevada
<br />NAME AND ADDRESS OF FACILITY Hites Funeral Home
<br />20 c. 438 W. Sunset Road, Henderson, Nevada 89015
<br />22a. On the basis of examination and/or Investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) and manner stated.
<br />v (Signature and Title)
<br />to DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH
<br />a
<br />ti
<br />c 22b.
<br />o8 PRONOUNCED DEAD (Mo., Day, Yr.) PRONOUNCED DEAD (Hour)
<br />22d. ON
<br />22c.
<br />22e. AT
<br />TYPE
<br />OR PRINT
<br />IN
<br />PERMANENT
<br />BLACK INK
<br />IF DEATH
<br />OCCURRED IN
<br />INSTITUTION
<br />SEE HANDBOOK
<br />REGARDING
<br />COMPLETION OF
<br />RESIDENCE ITEMS
<br />CONDITIONS
<br />IF ANY
<br />WHICH GAVE
<br />RISE TO
<br />IMMEDIATE
<br />CAUSE
<br />STATING THE
<br />UNDERLYING
<br />CAUSE LAST
<br />CAUSE OF
<br />DEATH
<br />. IMMEDIATE CAUSE 1/" (ENTER ONLY ON CAUSE EER ,
<br />P LINSFOOR (a) 'E) ,ANN .)
<br />ART (a) v
<br />PART
<br />II
<br />ACC., SUICIDE, ROM., UNDET.,
<br />OR PENDING INVEST.
<br />2 eot
<br />INJURY AT WORK
<br />(Specify Yes or No)
<br />28e.
<br />LOCAL FILE NUMBER
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER). (Type or Print)
<br />23a. William Christenson MD 806 Buchanan Boulder City NV
<br />(c)
<br />b I A 1 t Ut NtVAUA - UtYAH I MIN I OF HUMAN RtSUURCES
<br />DIVISION OF HEALTH - SECTION OF VITAL STATISTICS
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(70 - a v.04 ( R UC a
<br />DUE TO, OR AS A COHSE ENCE OF:
<br />CERTIFICATE OF DEATH
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not resulting in the underlying cause given In Part 1.
<br />DATE OF INJURY (Mo., Day, Yr.)
<br />28b.
<br />28f.
<br />HOUR OF INJURY
<br />28c. M
<br />PLACE OF INJURY -At home, farm, street, factory, office
<br />building, etc. (Specify)
<br />STATE REGISTRAR
<br />OUT THE
<br />HE CLARK
<br />DISTRICT
<br />DESCRiBE HOW INJURY OCCURRED
<br />28d.
<br />LOCATION.
<br />28g.
<br />CLARK COUNTY HEALTH DISTRICT
<br />625 Shadow Lane P.O. Box 3902
<br />Las Vegas, Nevada 89127
<br />702- 383 -1223
<br />Tax ID# 88- 0151573
<br />AUTOPSY (Specify
<br />Yes or No)
<br />26. No
<br />STREET OR R.F.D. No.
<br />201403850 -
<br />STATE FILE NUMBER
<br />LICENSE NUMBER
<br />23b. C.L SL
<br />Interval between onset and death
<br />Interval between onset and death
<br />Interval between onset and death
<br />WAS CASE REFERRED TO,
<br />CORONER (Spec! or o)
<br />27. Yes
<br />CITY OR TOWN STATE
<br />DEC! 19 2002
<br />No225138
<br />"CERTIFIED TO BE A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF
<br />VITAL STATISTICS, STATE OF NEVADA." This copy was issued by the Clark County Health District from State
<br />certified documents as authorized by the State Board of Health pursuant to NRS 440.175.
<br />DONALD S. KWALICK, MD, M.P.H.
<br />Registrar of Vital Statistics
<br />By:
<br />Date Issue
<br />
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