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la DECEASED-NAME (FIRST,MIDDLE,LAST,SUFFIX)
<br />Oliver Cromwell ASHTON JR
<br />2. DATE OF DEATH (MolDaylYear)
<br />November 12, 2012
<br />3a. COUNTY OF DEATH
<br />CIa k '
<br />3b, CITY, TOWN, OR LOCATION OF DEATH
<br />Las Vegas. '
<br />3. HOSPITAL OR OTHER INSTITUTION -Name(If not either, give street an
<br />1879 Racine Drive
<br />3e.lf Hosp. or Inst. indicate 00A,OP/Emer. Rm.
<br />Inpatient(Specify) .
<br />Home
<br />4. SEX
<br />/ . Male
<br />5, RACE White
<br />(Specify)
<br />6. Hispanic Origin? Specify
<br />No - Non
<br />7a. AGE-Last birthda;
<br />(Years)
<br />89
<br />7b. UNDER 1 YEAR
<br />7c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Moil:My/Yr)
<br />April 13, 1923
<br />HOURS I MINS
<br />MOS I UAYS .
<br />9a. STATE OF BIRTH (If not US/CA,
<br />name country) Iowa
<br />9b. CITIZEN OF WHAT COUNTRY
<br />N United States
<br />10. EDUCATION
<br />12
<br />11. MARITAL STATUS (Specify)
<br />Married
<br />12. SURVIVING SPOUSES NAME (Last name prior to first marriage)
<br />Bonita Lucile MAYFIELD
<br />13. SOCIAL SECURITY NUMBER
<br />507-32-8490
<br />14a, USUAL OCCUPATION (Give Kind of Work Done During Most of
<br />. Engineer
<br />14b. KIND OF BUSINESS OR INDUSTRY
<br />Space Program
<br />Ever in US Armed
<br />Forces? No
<br />15a. RESIDENCE-STATE
<br />Nevada
<br />15b. COUNTY
<br />Clark .
<br />15c CITY, TOWN OR LOCATION
<br />Las Vegas:
<br />15d. STREET AND NUMBER
<br />1879 Racine Drive
<br />15e. IN$IDE CITY
<br />LIMITS (Specify Yes
<br />or No) . Yes ,
<br />16. FATHERIPARENT - NAME (First Middle Last 'Suffix)
<br />Oliver Cromwell ASHTON
<br />17. MOTHER/PARENT - NAME (First Middle Last Suffix)
<br />Frances TAFFEE
<br />18a INFORMANT- NAME (Type or Print)
<br />Bonita Lucile ASHTON
<br />18b. MAILING ADDRESS (Street or R. F,D. Nc, City or Town, State, Zip)
<br />1879 Racine Drive Las Vegas, Nevada 89156
<br />19a. BURIAL, CREMATION, REMOVAL, OTHER (Specify)
<br />Anatomical Donation/Cremation
<br />19b. CEMETERY OR CREMATORY - NAME
<br />Desert Crematory
<br />19c. LOCATION City or Town State
<br />Las Vegas Nevada 89101
<br />20a. FUNERAL DIRECTOR - SIGNATURE (Or Pei Acting as Such)
<br />CHRIS WALTERS
<br />SIGNATURE AUTHENTICATED
<br />- 20b. FUNERAL DIRECTOF
<br />LICENSE NUMBER
<br />64
<br />20c. NAME AND ADDRESS OF FACILITY -
<br />Desert Memorial Cremation and Burial
<br />1111 Las Vegas Blvd N Las Vegas NV 89101
<br />-.-
<br />TRADE CALL - NAME AND ADDRESS
<br />>, .1 21a. To the best of my knowledge, death occurred at the time, date and place and due
<br />, 0 to the cause(s) stated .(Signature & Title) SIGNATURE AUTHENTICATED
<br />1 1- ROLAND PUA MD
<br />,.. u. , 22a On the basis of examination ancVor investigation, in my opinion death occurred
<br />t , 5 . at the time, date and place and due to the cause(s) stated (Signature & Title)
<br />_
<br />°- f" 22b. DATE SIGNED (Mo/Day/Yr)
<br />E r e
<br />. ,...,
<br />22c. HOUR OF DEATH
<br />.- 21b. DATE SIGNED (Mo/Day/Yr)
<br />u F November 16, 2012
<br />21c. HOUR OF DEATH
<br />20:03
<br />cti t 22d. PRONOUNCED DEAD (Mo/Day/Yr)
<br />0 0
<br />1--
<br />22e, PRONOUNCED DEAD AT (Hour)
<br />rti , 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />cc
<br />(Type or Print)
<br />23a. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER) (Type or Print)
<br />ROLAND PUN MD 9460 W. Flamingo Road Las Vegas, NV
<br />123b. LICENSE NUMBER
<br />12103'
<br />24a. REGISTRAR (Signature) SUSAN ZANNIS
<br />SIGNATURE AUTHENTICATED
<br />24b. DATE RECEIVED BY REGISTRAR
<br />(Mo/Day/Yr) November 19, 2012
<br />24c. DEATH DUE TO COMMUNICABLE DISEASE
<br />YES 1 NO r
<br />25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).) Interval between onset and death
<br />PART I (a) Cardiorespiratory arrest
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Coronary artery disease
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: 'N Interval between onset and death
<br />(
<br />{
<br />,, -„
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />) :
<br />(d) ,
<br />PART II OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not resulting in the underlying cause given in Part 1.
<br />26. AUTOPSY (Specil
<br />es or )
<br />Y No
<br />No
<br />27. WAS CASE
<br />REFERRED TO CORONER
<br />s pecify Yes or No) yes
<br />28a. ACC., SUICIDE, HOW, UNDET.
<br />OR PENDING INVEST. (Specify)
<br />281). DATE OF INJURY (Mo/Day/Yr)
<br />28c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY occuRReb
<br />28e. INJURY AT WORK (Specify
<br />Yes or No)
<br />28f. PLACE OF INJURY- At home, farm, street, factory, office
<br />building, etc. (Specify)
<br />28g. LOCATION STREET OR R.F.D. No CITY OR TOWN STATE
<br />,
<br />A
<br />CERTIFICATION OF VITAL RECORD
<br />.....
<br />TATE OF NEVADA
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE „a
<br />11.1
<br />Aiow,
<br />ai4it
<br />,o.
<br />CASE FILE NO. 3684244
<br />TYPE OR
<br />PRINT IN
<br />PERMANENT
<br />BLACK INK
<br />)*,
<br />3ttl
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<br />DECEDENT
<br />IF DEATH
<br />OCCURRED IN
<br />INSTITUTION SEE
<br />HANDBOOK
<br />REGARDING
<br />COMPLETION OF
<br />RESIDENCE
<br />ITEMS
<br />PARENTS
<br />)ISPOSITION
<br />TRADE CALL
<br />CERTIFIER
<br />REGISTRAR
<br />CAUSE OF
<br />DEATH
<br />CONDITIONS SF
<br />ANY WHICH
<br />GAVE RISE TO
<br />IMMEDIATE
<br />CAUSE -
<br />STATING THE
<br />UNDERLYING
<br />CAUSE LAST
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<br />DEPARTMENT OF HEALTH AND HUMAN SERVICES 20160
<br />DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH 1 2012018172
<br />STATE FILE NUMBER
<br />"CERTIFIED TO BE A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR
<br />OF VITAL STATISTICS, STATE OF NEVADA." This copy was issued by the Southern Nevada Health District
<br />from State certified documents authorized by state Board of Health pursuant to NRS 440.175.
<br />1111
<br />i a,wa&.'r "q e 0 AirgfahiI 15fUeifrni T.T1 'AVIBIS"faire T V
<br />LOCAL REGISTRAR
<br />247942 Registrar Vital Statistics
<br />DATE ISSUED: APR 0 1 2816 By:
<br />This copy not valid unless prepared on watermarked security paper disp eying date, seal and
<br />SOUTHERN NEVADA HEALTH DISTRICT • P.O. Box 3902 • Las Vegas , NV 89127 • 702-759-10
<br />•
<br />VRS-Rev-20120523a
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