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LOCAL FILE NUMBER '
<br />DECEASED -NAME First Middle Last
<br />Colleen Adair MEYER
<br />DATE OF DEATH (Month, Day, Year)
<br />,October 1, 1997
<br />- COUNTY I
<br />COY OF DEATH
<br />3a. Clark
<br />CRY, TOWN, OR LOCATION OF DEATH
<br />No. Las Vegas
<br />- HOSPITAL OR OTHER INSTITUTION -Name (If not either. give street and number)?,
<br />3c. Lake Mead Hospital
<br />11 Am Hoop on ient ( Inst. Spegtfy) indicate DOA, OP/Emer.
<br />. In
<br />3e. ICU
<br />SEX
<br />4 . Female
<br />Hispanic Origin? 8peeffy ❑ no It yes,
<br />AGE - .Last
<br />Birthday (Years)
<br />7a. 52
<br />UNDER 1 YEAR
<br />UNDER) DAY
<br />HOURS • MINS
<br />7c. •
<br />DATE OF BIRTH (Mo., Day, Yr) .
<br />8. October 10,1944
<br />RACE- (e.g., White, Black, American
<br />Indian, etc) ( Specify)
<br />5. White
<br />Was Decedent of yes it
<br />specify Mexican, Cuban, Puerta RIca , etc.
<br />6.
<br />MOS • DAYS
<br />7b.
<br />STATE OF BIRTH
<br />(I1 not U.S.A., name country)
<br />ga. Nebraska
<br />CITIZEN OF WHAT COUNTRY
<br />9b. U.S.A.
<br />Decedent's Education. Specify highest
<br />grade completed.
<br />10. 14
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED
<br />sped') Married
<br />11.
<br />SURVIVING SPOUSE (If wife, give maiden name)
<br />12. H. Frank Meyer
<br />SOCIAL SECURITY NUMBER
<br />13. 507 - 56 - 0296
<br />USUAL OCCUPATION (Give Kind of Work Done During Most of
<br />Working Life, Even II Retired)
<br />14a. Teacher's Assistant
<br />KIND OF BUSINESS OR INDUSTRY
<br />145. Education
<br />RESIDENCE -STATE
<br />158. Nevada
<br />COUNTY
<br />155. Clark
<br />CITY, TOWN, OR LOCATION
<br />150. Las Vegas
<br />STREET AND NUMBER
<br />15d. 6672 Rutgers
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />15e. '.. No
<br />FATHER-NAME First Middle Last
<br />18. Francis Rewerts
<br />MOTHER -MA /DEN NAME First Middle Last
<br />17. Elfrieda - Pappenhagen
<br />INFORMANT -NAME (Type` or Print)
<br />18a. H. Frank Meyer - Husband
<br />MAILING ADDRESS (Street or R.F.D. No., City or Town, State, Zip)
<br />1st, 6672 Rutgers, Las Vegas, Nevada 89115
<br />BURIAL, CREMATION, REMOVAL, OTHER (Specify)
<br />190. Burial
<br />CEMETERY OR CREMATORY -NAME
<br />191, Paradise Memorial Gardens
<br />LOCATION City or Town State
<br />19. Las Vegas, Nevada
<br />FUNERA L DI
<br />FUNERAL
<br />20a.�
<br />TOR-SIGN U
<br />R-SI
<br />p
<br />FUNERAL DIRECTOR
<br />LICENSE NUMBER
<br />205. 86
<br />AL
<br />NAME AND ADDRESS OF FACILITYDAVIS PARADISE VALLEY FUNER ROME
<br />me. 6200 S. Eastern Avenue, Las Vegas, Nevada 89119
<br />Z 218. To the best of my knowledge, deat ccu ed at the time, date and place and
<br />T g due to the cause(s) stated.
<br />"E-5. (Signature and 7711e)
<br />22a. On the basis of examination and/or Investigation, in my opinion death occurred
<br />at the time, date and place and 9 to the use(0) and manner at
<br />$ u (Signature and Title) ).- , +�
<br />m DATE SIGNED (Mo., Day, Yr.)
<br />Ep
<br />8K 21b.
<br />HOUR OF DEATH
<br />210.
<br />BE DATE SIGNED (Mo., Day, r.)
<br />Bo 225. ♦h �,".� /17
<br />HOUR OF DEAT
<br />22c. 2:4 P.
<br />S LL NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
<br />~ O 21d.
<br />2 PRONOUNCED DEAD (Mo., Day, Yr.)
<br />22d.ON 10-01-97
<br />PRONOUNCED DEAD (Hour)'
<br />22e.AT 2:45 P.M.
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, : MEDICAL EXAMINER, OR CORONER). (Type or Print.)
<br />23a G. ShhAldon Green, MD, Dep. M ed. Exam. , 1704 Pinto, Las Vegas, NV
<br />LICENSE NUMBER
<br />23b. 3004'
<br />1 REGISTRAR l
<br />24a. (Signature) )
<br />! � I
<br />IPJ XJ1W ` 9 ,W7
<br />DATE RECEIVEOBY 4o Dpy, Yr.)
<br />24b. OCT 16 19 9 1
<br />DEATH DUE TO COMMUNICABLE DISEASE
<br />O 24c. YES NO E
<br />25. IMMEDIATE CAUS (ENTER ONLY ONE CAUSE PER LINE F (a). ), AND (c).) : Interval between onset and death
<br />PART (al Bilateral pneumonia
<br />1
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS- Conditions contributing to death but not resulting In the underlying cause given in Part I.
<br />PART i
<br />u
<br />AUTOPSY (Specify
<br />Yes or Na)
<br />28. ,Yes
<br />WAS CASE REFERRED TO
<br />CORONER (Specify Yes or No)
<br />27. YeS
<br />ACC., SUICIDE, HOM., UNDET.,
<br />OR PENDING INVEST.
<br />( Speciry)
<br />2Ba.
<br />DATE OF INJURY (MO, l t St)
<br />28b.
<br />J
<br />HOUR OP INJURY .
<br />28c. M
<br />DESCRIBE HOW INJURY OCCURRED
<br />28d.
<br />INJURY AT WORK
<br />(Specify Yes or No)
<br />28e.
<br />PLACE OF INJURY -At home, fans, street, tectary, office
<br />building, etc. (Spa iSA
<br />28f.
<br />LOCATION. STREET OR R.F.D. No. , CITY OR TOWN -. STATE
<br />28g.
<br />:CERTIFICATION OF VITAL RECORD
<br />DECEDENT
<br />PARENTS
<br />DISPOSITION
<br />TATE DW NEVADA
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE'
<br />11
<br />e
<br />A
<br />4
<br />1
<br />TYPE
<br />OR PAINT
<br />IN
<br />PERMANENT
<br />BLACK INK
<br />IF DEATH
<br />OCCURRED IN
<br />INSIIT51106
<br />SEE HAIABDDI(
<br />REGARDING
<br />DompiErion OF
<br />RESIDENCE REMS
<br />CONDITIONS
<br />IF ANY
<br />WHICH GAVE
<br />RISE TO
<br />IMMEDIATE
<br />CAUSE
<br />STATING THE
<br />UNDERLYING
<br />CAUSE (AST
<br />USE OF
<br />EATH
<br />l 007221
<br />ItE
<br />IIIIII1IIIuhIIItI
<br />STATE OF NEVADA - DEPARTMENT OF HUMAN RESOURCES
<br />DIVISION OF HEALTH SECTION OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />5 9011511 UAW, q *Qp? ,WSUOY' '1136101:14 ' 9s 1 1 1 . .ue.
<br />i
<br />STATE REGISTRAR
<br />201705
<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 />R
<br />No.110114
<br />441096 Regist 0 Vital Sit ntics
<br />L
<br />DATE ISSUED: AUG 2 5 2017 By:
<br />This copy not valid unless prepared on watermarked security paper displaying date,' eal and sifjrfature of Registrar.
<br />SOUTHERN NEVADA HEALTH DISTRICT • P.O. Box 3902 Las Vegas , NV 89127 • 702 -759 -1010 • Tax ID # 88
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