|
TATE OF NEVADA )
<br />CERTIFICATION OF VITAL RECORD
<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 />RADE 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 />CASE FILE NO. 3654900
<br />TYPE OR
<br />PR'NTIN
<br />PERMANENT
<br />BLACK INK
<br />la. DECEASED -NAME (FIRST,MIDDLE,LAST,SUFFIX)
<br />Hjalmar Frank
<br />MEYER
<br />3b. CITY, TOWN, OR LOCATION OF DEATH
<br />Las Vegas
<br />5. RACE (Specify)
<br />9a. STATE OF BIRTH (If not US /CA,
<br />name country) Illinois
<br />13. SOCIAL SECURITY NUMBER
<br />323 -34 -3907
<br />15a. RESIDENCE - STATE
<br />Neval
<br />9b. CITIZEN OF WHAT COUNTRY
<br />United States
<br />15b. C
<br />OUNTY
<br />Clark
<br />16. FATHER/PARENT - NAME (First Middle Last Suffix)
<br />Hjalmar Emil MEYER
<br />18a. INFORMANT- NAME (Type or Print)
<br />Diana MEYER
<br />19a. BURIAL CREMATION, REMOVAL, OTHER (Specify)
<br />Burial
<br />3c. HOSPITAL OR OTHER INSTITUTION - Name(If not either, give street ar
<br />Desert Springs Hospital
<br />6. Hispanic Origin? Specify
<br />No - Non - Hispanic
<br />20a. FUNERAL DIRECTOR - SIGNATURE, (Or Person Acting as
<br />R TODD NOECKER
<br />SIGNATURE AUTHENTICATED
<br />Such)
<br />10.EDUCATION
<br />13
<br />14a. USUAL OCCUPATION (Give Kind of Work Done During. Most of
<br />Limo Driver
<br />15c. CITY, TOWN OR LOCATION
<br />Las Veaas
<br />20b. FUNERAL DIRECTOF
<br />LICENSE NUMBER
<br />813
<br />T 21a. To the best of my knowledge, death occurred at the time, date and place and due
<br />to the cause(s) stated.(Signature & Title) SIGNATURE AUTHENTICATED
<br />NICHOLAS CALICA MD
<br />E 21b. DATE SIGNED (Mp /Day/Yr) 21c. HOUR OF DEATH
<br />May 15, 2012 08:32
<br />21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />(Type or Print)
<br />E
<br />22b. DATE SIGNED (Mo /Day/Yr)
<br />oz
<br />Ca),
<br />m o 22d PRONOUNCED DEAD (Mo/Day/Yr)
<br />O 0
<br />23a. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIA 1, MEDICAL EXAMINER, OR CORONER) (Type or Print)
<br />NICHOLAS CALICA MD 2065 E. Flamingo Road Las Vegas, NV 89119
<br />24a. REGISTRAR (Signature)
<br />NINETTE HARRINGTON
<br />SIGNATURE AUTHENTICATED
<br />PART II OTHER SIGNIFICANT CONDITIONS- Conditions contributing to death but not resulting in the underlying cause given in Part 1.
<br />Acute renal failure, ventilator dependent respiratory failure
<br />28a. ACC., SUICIDE, HOM., UNDET.
<br />OR PENDING INVEST. (Specify)
<br />28e. INJURY AT WORK (Specify
<br />Yes or No)
<br />28b. DATE OF INJURY (MO /Day/Yr)
<br />28c. HOUR OF INJURY
<br />28f. PLACE OF INJURY- At home, farm, street, factory, office
<br />building, etc. (Specify)
<br />11. MARITAL STATUS (Specify)
<br />Married
<br />2. DATE OF DEATH (Mo /Day/Year)
<br />May 15, 2012
<br />3e.lf Hosp. or Inst. indicate DOA,OP /Emer. Rm.
<br />Inpatient(Specify)
<br />Inpatient
<br />:R 1 YEAR 7c. UNDER 1' bAY
<br />DAYS HOURS I MINS
<br />14b. KIND OF BUSINESS OR INDUSTRY
<br />Transporation
<br />15d. STREET AND NUMBER
<br />3a. COUNTY OF DEATH
<br />Clark
<br />4. SEX
<br />MaIB
<br />8. DATE OF BIRTH (Mo /Day/Yr)
<br />September 04, 1941
<br />12. SURVIVING SPOUSE'S NAME (Last name prior to first marriage)
<br />Diana BELL
<br />15e. INSIDE CITY
<br />LIMITS (Specify Yes
<br />or No) Yes
<br />17. MOTHER /PARENT - NAME (First Middle Last Suffix)
<br />Pearl Gladys EHRENEREICH,
<br />18b. MAILING ADDRESS (Street or R.F.D. No, City or Town, State, Zip)
<br />6672 Rutgers Drive Las Vegas, Nevada 89156
<br />19b. CEMETERY OR CREMATORY - NAME
<br />Davis Memorial Park
<br />19c. LOCATION City or Town State
<br />Las Vegas Nevada 89119
<br />20c. NAME AND ADDRESS OF FACILITY
<br />Davis Funeral Home and Memorial Park
<br />6200 S Eastern Las Vegas NV 89119
<br />TRADE CALL - NAME AND ADDRESS
<br />22a. On the basis of examination and/or investigation, in my opinion death occurred
<br />° tl at the time, date and place and due to the cause(s) stated. (Signature & Title)
<br />f
<br />24b. DATE RECEIVED BY REGISTRAR
<br />(Mo /Day r) May 16, 2012
<br />22c. HOUR OF DEATH
<br />22e. PRONOUNCED DEAD AT (Hour)
<br />23b. LICENSE NUMBER
<br />8250
<br />24c. DEATH DUE TO COMMUNICABLE DISEASE
<br />YES ❑ NO
<br />25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).)
<br />PART I (a) Cardiogenic shock
<br />(b)
<br />(c)
<br />(d)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Coronary artery disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Interval between onset and death
<br />2 Weeks
<br />Interval between onset and death
<br />Interval between onset and death
<br />Interval between onset and death
<br />26. AUTOPSY (Specit
<br />Yes or No)
<br />No
<br />27. WAS CASE
<br />REFERRED TO CORONER
<br />(Specify Yes or No)
<br />No
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />28g. LOCATION STREET OR R.F.D. No. CITY OR TOWN STATE
<br />Information Corrected, State Affidavit# 56976, 06/08/2012 - 2
<br />441099
<br />DEPARTMENT OF HEALTH AND HUMAN SERVICES Q, O 5
<br />DIVISION OF PUBLIC AND BEHAVIORAL HEALTH •
<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
<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 />Regis ir o ital St. ' =tics
<br />By.
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE
<br />This copy not valid unless prepared on watermarked security paper displaying date,leal and sig ure of Registrar. �.
<br />SOUTHERN NEVADA HEALTI -' DISTRICT • P.O. Box 3902 • Las Vegas /, NV 89127 • 702 -759 -1010 • Tax ID # 89- 0151573
<br />VRS- Rev- 20120523a
<br />i
<br />k
<br />ir
<br />iilPk�°&I1A = t' r 1, 4 r8%.8-
<br />t
<br />
|