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la. DECEASED -NAME (FIRST,MIDDLE,LAST,SUFFIX)
<br />Bonita L ASHTON •
<br />2. DATE OF DEATH (Mo /Day(Year)
<br />.March 09, 2016
<br />3a. COUNTY OF DEATH
<br />Clark
<br />3b. CITY, TOWN, OR LOCATION OF DEATH.
<br />Vegas
<br />Las Ve g
<br />3c. HOSPITAL OR OTHER INSTITUTION - Name(If not either, give street an
<br />1546 N. Christy
<br />y Lane
<br />3e.lf Hosp. or Inst. indicate DOA,OP /Emer. Rm.
<br />Inpatient (Specify) Acres > roup Home
<br />Golden G
<br />4. SEX
<br />.Female
<br />5. RACE White
<br />(Specify)
<br />6. Hispanic Origin? Specify
<br />No - Non- Hispanic
<br />7a. AGE -Last birthday
<br />(Years) 93
<br />7b. UNDER 1 YEAR 7c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo /Day/Yr)
<br />February 12,1923
<br />MUS I DAYS HOURS I MINS
<br />9a. STATE OF BIRTH (If not US /CA,
<br />name country) Nebraska
<br />9b. CITIZEN OF WHAT COUNTRY
<br />United States
<br />10. EDUCATION
<br />14
<br />11. MARITAL STATUS (Specify)
<br />Widowed
<br />12. SURVIVING SPOUSE'S NAME (Last name prior to first manage)
<br />i
<br />13. SOCIAL SECURITY NUMBER
<br />522 -60 -6430
<br />14a. USUAL OCCUPATION (Give Kind of Work Done During Most of
<br />Sales Clerk
<br />14b. KIND OF BUSINESS OR INDUSTRY
<br />Retail
<br />Ever in US Armed
<br />Forces? No
<br />15a. RESIDENCE - STATE
<br />Nevada
<br />1511 COUNTY
<br />Clark
<br />15c. CITY, TOWN OR LOCATION
<br />Las Vegas /
<br />15d. STREET AND NUMBER
<br />1879 Racine Drive
<br />15e. INSIDE CITY
<br />LIMITS (Specify Yes
<br />or No) Yes
<br />16. FATHER/PARENT - NAME (First Middle Last Suffix)
<br />Leo James MAYFIELD
<br />17. MOTHER/PARENT - NAME (First Middle Last Suffix)
<br />Lucille CAMPBELL
<br />18a. INFORMANT- (Type or Print)
<br />Frances Kaye ROSE
<br />leb. MAILING ADDRESS (Street or R.F.D. No, City or Town, State, Zip)
<br />1879 Racine Drive Las Vegas, Nevada 89156
<br />19a. BURIAL, CREMATION, REMOVAL, OTHER (Specify)
<br />Donation / Cremation
<br />19b. CEMETERY OR CREMATORY - NAME
<br />La Paloma Funeral Services
<br />19c. LOCATION City or Town State
<br />Las Vegas Nevada
<br />20a. FUNERAL DIRECTOR - SIGNATURE (Or Person Acting as Such)
<br />RYAN BOWEN
<br />SIGNATURE AUTHENTICATED'
<br />20b. FUNERAL DIRECTOF
<br />LICENSE NUMBER
<br />810
<br />20c. NAME AND ADDRESS OF FACILITY
<br />Simple Cremation and Burial Services
<br />3620 N Rancho Drive #1 Las Vegas NV 89130
<br />TRADE CALL - NAME AND ADDRESS
<br />a
<br />to the cause(s) stated.(Signature & Title) SIGNATURE AUTHENTICATED
<br />> a 21 a. To the best of my knowledge, death occurred at the time, date and place and due
<br />. g
<br />v STEPHEN P DUBIN M.D.
<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) stated. (Signature & Title)
<br />s
<br />o
<br />E S''' 2 2b. DATE SIGNED (Mo /Day/Yr)
<br />� _
<br />22c. HOUR OF DEATH
<br />e ' 21b. DATE SIGNED (Mo/Day/Yr)
<br />° � March 28, 2016
<br />U
<br />LL
<br />21c. HOUR OF DEATH
<br />\ 23:15
<br />O
<br />m o 22d. PRONOUNCED DEAD (Mo/Day/Yr)
<br />r
<br />22e. PRONOUNCED DEAD AT (Hour)
<br />CO , 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />r o ( Type or Print)
<br />23a. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN „MEDICAL EXAMINER, OR CORONER) (Type or Print)
<br />Stephen P Dubin M.D. 5741 Fort Apache Las Vegas, NV 89148
<br />23b. LICENSE NUMBER
<br />13772
<br />24a. REGISTRAR (Signature) NANCY BARRY
<br />SIGNATURE AUTHENTICATED
<br />24b. DATE RECEIVED BY REGISTRAR
<br />(Mo /Day/Yr) March 29, 2016
<br />24c. DEATH DUE TO COMMUNICABLE DISEASE
<br />YES 0 NO 1
<br />25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR'(a), (b), AND (c).) Interval between onset and death
<br />PART I (a) Age Related Physical Disability 03/09/16
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OR Interval between onset and/death
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />(d) ,
<br />PART 11 OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not resulting in the underlying cause given in Part 1.
<br />26. AUTOPSY (Specil
<br />Yes or No)
<br />No
<br />27 WAS CASE
<br />REFERRED TO CORONER
<br />(SpecitY Yes or No) Yes
<br />28a. ACC., SUICIDE, HOM„ UNDET.
<br />OR PENDING INVEST. (Specify)
<br />28b. DATE OF INJURY (Mo /Day/Yr)
<br />28c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<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.0 No CITY OR TOWN STATE
<br />•
<br />/y
<br />II
<br />CASE FILE NO. 3883114
<br />II
<br />(
<br />3' TYPE OR
<br />PRINT IN
<br />PERMANENT
<br />BLACK INK
<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 IF
<br />ANY WHICH
<br />GAVE RISE TO
<br />IMMEDIATE
<br />CAUSE -
<br />STATING THE
<br />UNDERLYING
<br />CAUSE LAST
<br />E \TAD ' a
<br />1y
<br />CERTIFICATION OF VITAL RECORD
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<br />TATE OF NEVADA
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<br />HEALTH +�� ►�id►nA4 A
<br />DEPARTMENT OF HEALTH AND HUMAN SERVIC
<br />DIVISION OF PUBLIC AND BEHAVIORAL
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />LOCAL REGISTRAR
<br />`CERTIFIED TO BE A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR VRS- Rev- 20120523a
<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.
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<br />247948 Registrar Vital Statistics
<br />DATE ISSUED: APR 0 1 2016 By:
<br />copy not valid unless prepared on watermarked security paper displaying date, seal and sign ture of Registrar.
<br />SOUTHERN NEVADA HEALTH DISTRICT • P.O. Box 3902 • Las Vegas , NV 89127 • 702 759 10 ax ID # 88-0151573
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<br />2016005403
<br />STATE FILE NUMBER
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