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TOWN, OR LOCATION OF DEATH
<br />STATE OE NL ADA- DE 1 ARTM1NT Ol+ 1It7MAN RESOURCES
<br />SOON OF HEALTH - VITAL STATISTICS
<br />ISTICS
<br />sT,surFlX
<br />CERTIFICATE OF DEATH
<br />•• ••
<br />,FDEATH
<br />IERMmENT ',
<br />BLAAk INK
<br />ISPOSITION
<br />RADE CALL
<br />CERTIFIE
<br />3b.
<br />° Las Vegas
<br />DECEDENT.
<br />mss. RACE White
<br />(sway)
<br />2EGISTRAR
<br />CAUSE OF
<br />DEATH
<br />:ONUiTIONS IF
<br />ANY WHICH
<br />SAVE RISE TO
<br />IMMEDIATE
<br />CAUSE ->
<br />STATING THE
<br />UNDERLYING
<br />CAUSE LAST
<br />ow !NM
<br />PART II
<br />28e. ACC., SUICIDE, HOM., UNDET.
<br />OR PENDING INVEST. (Specify)
<br />26e. INJURY AT WORK (Specify
<br />Yes or No)
<br />• - T • • • - r1 .-,'I re . not er, a °' ,. or'Inst. ICeta = . Rm. 4. SEX
<br />and number) ' Inpatient(Speay)
<br />Inpatient Mi - _ _
<br />Las VentBn cify a Retirement COComm TC. UNDER 1 DAY DATEOF BIRTH (MotiTa33t
<br />Ffi nic Origin? (Spe. fit"E - Lei S „UNDER 1 YEAR
<br />,7e.
<br />fRI Hispani4 wnnday tY ors MOS I DAYS 'HOURS ( MItVS Uctl�tser 30 1
<br />,,, y t wife, givrtv=
<br />- CITIZEN OF - WHAT COUNTRY 1fl. y, x+UCAf 11. MARR f4 r ER MARRIED, WIDOWED. 11 SUtna t name) SPOUSE ` ES
<br />United States , 14 DIVORCED (Seedy) Married
<br />14a. USUAL OCCUPATION (Give Kind of Work Done During Most of 14b. KIND OF lam ESS NDUSTRY Ever in US Armed
<br />Wonting Life, E en It Retired) Truck Driver rue n
<br />15d. STREET AND NUMBER
<br />IF DEATH 9a STATE OF BIRTH (If WAS
<br />OCCURRED IN name country) Nebraska
<br />teSTrr11TION
<br />tEEmidtOBOOIc 13. SOC(AL SECURITY; NUMBER
<br />qt. CrARC X 1& 52 -163$
<br />OMN- ETKNNOF=
<br />litlksIDeNce == r15a RESIDENCE - STA
<br />'rTE6H =-
<br />1= ;, ` Nevada
<br />16. FATHER - NAME (First Middle Last Suffix)
<br />PARENTS Lewis DUBBS
<br />ns s-3 La.�s HCllx e: u ors r , :e,y ax iowli, a'iakb, 6i
<br />C � . a of E
<br />i; 442 , . Nebraska 68801
<br />Mary DU88S St Grand Island,
<br />LtION 'City or flown State
<br />28b. DATE OF INJURY iMdDayPer)
<br />CITY, TOWN OR LOCATION
<br />Las Vegas
<br />26f. PLACE OF INJURY- At home, farm, street, factory, office 28g. LOCATION
<br />building; etc. (Specify)
<br />10401 W. Charleston BI
<br />17. MOTHER - NAME (First Middle Last Suffix)
<br />Lucy PACKER
<br />Henderson Nevada 89011
<br />19a. BURIAL, CREMATION, REMOVAL OTHER (Spectty)119h. CEMETERY OR CREMATORY - NAME
<br />Hites Crematory
<br />RAL 21x. NAME: AND ADDRESSOF FACILITY
<br />LICENSE
<br />Hites Funeral Home
<br />6g 438 W Sunset Road Henderson NV 89011
<br />Cremation, - -
<br />20a. FUNERAL DIRECTOR SIGNATURE (Or Person Acting as.S uch)
<br />JAMESf LEE
<br />SI TUREAUTHEM CATER
<br />1 20b.FUNE
<br />DIRECTOR
<br />TRADE CALL - NAME AND ADDRESS
<br />i 21a. To the best of my knowledge, death occurred at the time, date and place and
<br />0 due to the cause(s) stated. (Signature & Title) SIGNATURE AUTHENTICATED
<br />ID = - . AJAY KUMAR NELLUTLA M.D.
<br />' 21b. DATE SIGNED (MoIDayfYr) 21c. HOUR OF DEATH
<br />o August 19, 2009 22:20
<br />A �-` 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />(Type or Print)
<br />Ajay Kumar Neliutla M.D. 1050 Whitney Ranch Drive, #201 Henderson, NV 89014
<br />(Signature)
<br />24b DATE #2ECEtVEDBY REGISTRAR
<br />yr) August 19, 2009
<br />22a. On the basis of examination and/or investigation, in my opinion death occurred at
<br />5 the time, date and place and - the cause(s) stated. (Signature & Title)
<br />LL
<br />g k 22b. DATE SIGNED (MG/Ow/NTT
<br />i
<br />g' R 22d. PRONOUNCED DEAD (Mo/DaylYr) 22e. PRONOUNCED DEAD AT (Hour)
<br />t
<br />22e. HOUR OF DEATH
<br />ADDRESS NAME AND SS OF CERTIFIER (PHYSICIAN ATTENDING PHYSICIAN, MEDICAL E ti 1 -t UER. OR CORONER) (Type or Print)
<br />231. LICENSE NUMBER
<br />10766
<br />NINETTE HARRINGTON (�
<br />SIGNATURE AUTHENTICATED
<br />25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).)
<br />PART I (e) Cardiopulmonary arrest
<br />24a. REGISTRAR
<br />1 24c, DEATH DUE TO COMMUNICABLE DISEASE
<br />YES 0 NO
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b) Metastatic colon cancer, chronic obstructive pulmonary disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEOUtNCE OF:
<br />Interval between onset and death
<br />Interval between onset and death
<br />Interval between onset and death
<br />Interval between onset and death
<br />28c. HOUR OF INJURY 28& DESCRIBE HOW INJURY OCCURRED
<br />I
<br />STATE REGISTRAR
<br />15e INSIDE +
<br />UNITS (Specify ,V t5�
<br />126. AUTOPSY a� 1 27. WAS CASE REFERRED
<br />Yes
<br />1 if IVO r I n rn�°CHCrt ;`r Y r
<br />IC;,'cc mNo)
<br />STREET OR R.F.D. No. CITY OR TOWN STATE
<br />"CERTIFIED TO BE A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF VITAL STATISTICS
<br />STATE OF NEVADA." This copy was issued by the Southern Nevada Health District from State certified documents as authorized by t i
<br />State Board of Health pursuant to NRS 440.175.
<br />NOT VALID WITHOUT THE RAISED
<br />SEAL OF THE SOUTHERN NEVADA
<br />HEALTH DISTRICT T "
<br />Date Issued:
<br />Lawrence K. Sands, D.O., M.P.H.
<br />Registrar of Vital Statistics
<br />By:
<br />SOUTHERN NEVADA HEALTH DISTRICT • 625 Shadow Lane P.O. Box 3902 ♦ Las Vegas, Nevada 89127 • 702 - 759 -1010 ♦ Tax ID# 88-0151573
<br />
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