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� O <br />i C <br />�M <br />•i �• <br />X <br />To d Coffolftd by CERTIFVINO PMYSICIAtd C <br />738 To (M best of my knowtddps. death occurf@4 at tte tank, date <br />cwm(s) stated. <br />r r <br />1allM"Il <br />i <br />at <br />0 <br />cam <br />a <br />SNOW The <br />1 L4 <br />Y> <br />Tw <br />CLERK & RECORDER° AN <br />Sofia wile I <br />i <br />f <br />t <br />1 <br />t <br />L <br />. <br />� <br />- <br />Cr F DEATH <br />104836 <br />- <br />►oCA►i�NUAiEER STATEtA,E1W)A�EA <br />•IM�nm" I MIDDLE ILAST DE1t <br />OM W MAT" tw »tilt' Yrl z ti <br />cw ATM - - - <br />11Mgq AmMtCanMpiaD -Lest <br />wt lNl} <br />1 <br />1 Y Dt1CYc) <br />__ <br />iRsitt 39RwYf <br />se nM+ Z6 1927 <br />CITY. T LOCATIOM OF OEATM <br />At on Gym" MasTRUTIQN • Now to rtes w flee►_ 00 eatst ee Raw <br />W � . GAR"s(Sieell� <br />m . <br />ta3 <br />ow- h�i/ <br />F m (M Col in U lt# -. <br />CIT12EN OF YMNT <br />1i <br />t11Y MADIYItw. Lt/OUItE <br />7s. ..� <br />(11 NOW Oft �R A&"$ . <br />LMeY lIe1MIMte <br />heel <br />ONE <br />(sF.eMY) <br />,. <br />' <br />11LIee Ousesle <br />E , <br />USUAL OCCUPATION (One aalle N w" eeM OA" 1tMO0i oti$O M 011 EVER v <br />t10CtrtL MAMi# <br />i <br />Oa wW10y 6te, wwl U nwea) AIWYDFn ICU a.."wseteas <br />13b. t1111111F MF <br />OIL- <br />"- <br />LIE31DESICE- tLSTATE <br />COUNTY <br />CRV,TOWN.ORLOCAT <br />STREETANOmull R . <br />-a <br />��!! <br />IlsacerLuiseatia) - <br />( <br />fk <br />Lib. <br />tSc. <br />ts0. t3k <br />iATMER.)LAyt i1113T A.UMXE LAST sg7►tEf1- 81ARiEMPLA� <br />GIRST #L100LE LAST <br />yy <br />p_ <br />1 tf • <br />3 <br />OIIMAMT- ISII�(Typeothint) <br />MAILON()ADDRESS STREETOfMF0 O:'. CITYORTtiWN - STATE Ztv- - - -_ - -"- <br />i <br />- <br />i <br />. <br />Oq MATOftY -IIA� - <br />- <br />LOCATION C/TYOIITOt/YN ATE <br />tl1� <br />tab <br />1 i <br />- <br />L�iJ111AL CRUMTION, REMOVAL. OTHER (Spa ty <br />- - - I <br />UARY OR OTHER -NAME AND ADOR65S P � � 1R96 <br />I P. • <br />� O <br />i C <br />�M <br />•i �• <br />X <br />To d Coffolftd by CERTIFVINO PMYSICIAtd C <br />738 To (M best of my knowtddps. death occurf@4 at tte tank, date <br />cwm(s) stated. <br />Vest) <br />/1i _ �• � �Mterssar <br />On the "us of a.am:nafbn and/or invest yPt.Otl. in my opinior$ death <br />%p omffv J"I Mo M04" and des to IN ewakts) stead. <br />tt GY ATTCROMM PHYSICIAN IF OTHER THAN CERTIFIER IType or Rnn) PRONOUNCED DEAMMO. Day. VT.) P <br />?ad ON 9 T w per; 1ea7 249 AT 7 =1A "O M <br />E AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER) (Type or Print) <br />Jaaea R. Mitchell Deputy Coroner, 113 South .W112w n, Dosemm Nantang 5971 <br />AL REGISTRAR /i' /. DATE RECEIVED OV LOCAL REGISTRAR (Mo. <br />ewrm> �.f f•f►il 2w la, 174/ <br />MEDIATE IATE CA USE (ENTER OMLV ONE CAUM PER LINE FOR (e). (D). AND (c)) wa... aw.MW aaM a erM <br />PART 1 (a) _I Tnatant <br />Coma <br />DUETV,G A U neanwaa•aanaraere. <br />{ (b�� - I wlnnt_ <br />DUE 70. A' N E Oi <br />(cl f.r. ��. finov i�nt, las eT±t of et1± I . <br />RT 11 OTHER t{IGNMlCr1NT QONOTTIQITS • t ane,IgM cunrnaNYq b OMN sea Mt reUlN w Gear rwn n Fjn IU/ yes a l I n ISMC�w watbl D TO CBMZ <br />1300 W <br />• N Mama. tales oraN lattory, ofte <br />' r <br />:t <br />�A <br />STATE OF MONTANA I ___ _ ......_ ... .. . <br />ss <br />County of Gallatin <br />I hereby certify that this is a Iutl,. true and correct copy of the document now on file <br />-and of record,in my office. <br />Witness my hand and Official Seal this - day of , 19 <br />Gerald R. Wine, 0 rk dt 13ccor4fer <br />11y: <br />Ego <br />k+ <br />collsrtar . <br />1allM"Il <br />i <br />at <br />0 <br />cam <br />a <br />SNOW The <br />1 L4 <br />i <br />f <br />t <br />1 <br />t <br />L <br />. <br />� <br />Vest) <br />/1i _ �• � �Mterssar <br />On the "us of a.am:nafbn and/or invest yPt.Otl. in my opinior$ death <br />%p omffv J"I Mo M04" and des to IN ewakts) stead. <br />tt GY ATTCROMM PHYSICIAN IF OTHER THAN CERTIFIER IType or Rnn) PRONOUNCED DEAMMO. Day. VT.) P <br />?ad ON 9 T w per; 1ea7 249 AT 7 =1A "O M <br />E AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER) (Type or Print) <br />Jaaea R. Mitchell Deputy Coroner, 113 South .W112w n, Dosemm Nantang 5971 <br />AL REGISTRAR /i' /. DATE RECEIVED OV LOCAL REGISTRAR (Mo. <br />ewrm> �.f f•f►il 2w la, 174/ <br />MEDIATE IATE CA USE (ENTER OMLV ONE CAUM PER LINE FOR (e). (D). AND (c)) wa... aw.MW aaM a erM <br />PART 1 (a) _I Tnatant <br />Coma <br />DUETV,G A U neanwaa•aanaraere. <br />{ (b�� - I wlnnt_ <br />DUE 70. A' N E Oi <br />(cl f.r. ��. finov i�nt, las eT±t of et1± I . <br />RT 11 OTHER t{IGNMlCr1NT QONOTTIQITS • t ane,IgM cunrnaNYq b OMN sea Mt reUlN w Gear rwn n Fjn IU/ yes a l I n ISMC�w watbl D TO CBMZ <br />1300 W <br />• N Mama. tales oraN lattory, ofte <br />' r <br />:t <br />�A <br />STATE OF MONTANA I ___ _ ......_ ... .. . <br />ss <br />County of Gallatin <br />I hereby certify that this is a Iutl,. true and correct copy of the document now on file <br />-and of record,in my office. <br />Witness my hand and Official Seal this - day of , 19 <br />Gerald R. Wine, 0 rk dt 13ccor4fer <br />11y: <br />Ego <br />k+ <br />