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DEPARTMENT OF HEALTH,, <br />CERTIFICATE OF DEATH <br />FACT OF DEATH NUMBER STATE FILE NUMBER <br />4567 140 -2017- 004562 <br />DECEDENTS INFORMATION: DATE FILED: 08/01/2017 <br />NAME: WILLIAM LYLE LORE <br />ALIAS: <br />SEX: MALE SOCIAL SECURITY NUMBER: 521 -52 -0463 ARMED FORCES: YES <br />DATE OF DEATH: 07/23/2017 DATE OF BIRTH: 06/08/1934 AGE: 83 YEARS <br />PLACE OF DEATH INFORMATION: <br />TYPE: EMERGENCY ROOM 1 OUTPATIENT <br />FACILITY NAME OR ADDRESS: ; STURGIS REGIONAL HOSPITAL STURGIS MEADE SOUTH DAKOTA <br />DISPOSITION INFORMATION: <br />METHOD: CREMATION <br />CEMETERY: <br />LOCATION: <br />CREMATORY: BLACK HILLS CREMATORY, <br />LOCATION: STURGIS SOUTH DAKOTA <br />DEMOGRAPHIC INFORMATION: <br />RESIDENCE: 5652 VALLEY ROAD. ALLIANCE BOX BUTTE NEBRASKA 69301 <br />PLACE OF BIRTH: NEBRASKA UNITED STATES OF AMERICA MARITAL STATUS: MARRIED <br />SURVIVING SPOUSES NAME, IF WIFE MAIDEN NAME: MARY WILES <br />FATHERS NAME: HOWARD LORE <br />MOTHERS NAME PRIOR TO FIRST MARRIAGE: SADIE? WILKINS <br />INFORMANT INFORMATION: <br />INFORMANTS NAME: MARY LORE RELATIONSHIP; SPOUSE <br />MAILING ADDRESS: PO BOX 94 ALLIANCE, NEBRASKA 69301 <br />F / � tI HOI E: BLACK HILLS FUNERAL HOME AND CREMATION SERVICE 1440 JUNCTION STURGIS SOUTH DAKOTA 57785 <br />FUNERAL SERVICE LICENSEE: MONCUR DEAN L <br />CAUSE OF DEATH PART I: MEDICAL CERTIFICATE <br />SUDDEN CARDIAC ARREST NOS <br />PART II: <br />CORONER CONTACTED: YES AUTOPSY PERFORMED: NO AUTOPSY AVAILABLE ° <br />ACTUAL OR PRESUMED TIME OF DEATH: 1229 MANNER OF D a f��TRNL CAUSES <br />INJURY INFORMATION: <br />DATE OF INJURY: <br />TIME OF INJURY: . <br />INJURY AT WORK: TYPE OF WORK: <br />PLACE OF INJURY: <br />LOCATION OF INJURY: <br />HOW THE INJURY OCCURRED: <br />CERTIFIER: DEMO CALEB A <br />CERTIFIERS ADDRESS: 1400 MAIN STREET STURGIS SOUTH DAKOTA 57785 <br />LICENSE NO: 1534 <br />St? LIC <br />This is a true certification of the official Vital Record filed in the Department` of Health as provided in Chapter <br />34 -25 of the SOUTH DAKOTA CODIFIED LAWS. <br />ISSUED BY MEADE COUNTY REGISTER OF DEEDS <br />MARIAH R POKORNY, STATE REGISTRAR REGISTER OF DEEDS <br />DATE ISSUED:. AUGUST 02, 2017 <br />INTERVAL: <br />IDVALID ALI <br />DVALI •�A,•/ DV <br />VALI <br />ID VALID <br />VALI DALID VALI <br />LI VALID <br />ANY ALTERATION, ERASURE OR DUPLICATION VOIDS THIS CERTIFICATE <br />