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STATE OF NEVADA
<br />CERTIFICATION OF VITAL RECORD
<br />DEPARTMENT OF HEALTH AND HUMAN SERVICFtS
<br />DIVISION OF PUBLIC AND BEHAVIORAL HEALTH U 1 90 3 3 9
<br />VITAL STATISTICS
<br />CASE FILE NO. 4057091 CERTIFICATE OF DEATH
<br />TYPE OR
<br />PRINT IN
<br />PERMANENT
<br />BLACK INK
<br />ECEDENT
<br />IF DEATH
<br />OCCURRED IN
<br />INSTITUTION SEE
<br />HANDBOOK
<br />REGARDING
<br />COMPLETION OF
<br />RESIDENCE
<br />ITEMS
<br />PARENTS
<br />SPOSITION
<br />RADE CALL
<br />CERTIFIER
<br />EGISTRAR
<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 />2018024366
<br />STATE FILE NUMBER
<br />1a. DECEASED -NAME (FIRST,MIDDLE,LAST,SUFFIX)
<br />Gary Dean RUFF
<br />2. DATE OF DEATH (Mo/Day/Year)
<br />December 19, 2018
<br />3a. COUNTY OF DEATH
<br />Clark
<br />3b. CITY, TOWN, OR LOCATION OF DEATH •
<br />Las Vegas
<br />3c. HOSPITAL OR OTHER INSTITUTION-Name(If not either, give street an
<br />University Medical Center
<br />3e.lf Hosp. or Inst. indicate DOA,OP/Emer. Rm,
<br />Inpatient(Specify)
<br />Inpatient
<br />4, SEX
<br />Male
<br />5. RACE (Specify)
<br />White
<br />6. Hispanic Origin? Specify
<br />No - Non -Hispanic
<br />7a. AGE -Last birthday
<br />(Years)
<br />79
<br />7b. UNDER 1 YEAR
<br />7c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo/Day/Yr)
<br />08, 1939
<br />MOS LAYS
<br />HOURS MINS
<br />IDecember
<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 />12
<br />11. MARITAL STATUS (Specify)
<br />Married
<br />12. SURVIVING SPOUSES NAME (Lest name prior to first marriage)
<br />Barbara J WHITE
<br />13. SOCIAL SECURITY NUMBER
<br />505-44-3682
<br />14a. USUAL OCCUPATION (Give Kind of Work Done During Most of
<br />Clerk
<br />14b. KIND OF BUSINESS OR INDUSTRY
<br />United States Postal Service
<br />Ever in US Armed
<br />Forces? Yes
<br />15a. RESIDENCE - STATE
<br />Nebraska
<br />15b. COUNTY
<br />Hall
<br />15c. CITY, TOWN OR LOCATION
<br />Grand Island
<br />15d. STREET AND NUMBER
<br />1622 W Charles Street
<br />15e. INSIDE CITY
<br />LIMITS (Specify Yes
<br />or No) Yes
<br />16. FATHER/PARENT - NAME (First Middle Last Suffix)
<br />Edward RUFF
<br />17. MOTHER/PARENT - NAME (First Middle Last Suffix)
<br />Nettie NEITHAM
<br />18a. INFORMANT- NAME (Type or Print)
<br />Barbara J RUFF
<br />18b. MAILING ADDRESS (Street or R.F.D. No, City or Town, State, Zip)
<br />1622 W Charles Street Grand Island, Nebraska 68801
<br />19a. BURIAL, CREMATION, REMOVAL, OTHER (Specify)
<br />Cremation
<br />19b. CEMETERY OR CREMATORY - NAME
<br />Palm Crematory
<br />19c. LOCATION City or Town State
<br />Las Vegas Nevada 89101
<br />20a. FUNERAL DIRECTOR - SIGNATURE (Or Person Acting as Such)
<br />MARIELLE J LANDRY
<br />SIGNATURE AUTHENTICATED
<br />20b. FUNERAL DIRECTOF
<br />LICENSE NUMBER
<br />FD886
<br />20c. NAME AND ADDRESS OF FACILITY
<br />Affordable Cremation and Burial Services
<br />2127 W Charleston Blvd Las Vegas NV 89102
<br />TRADE CALL - NAME AND ADDRESS
<br />o a 21a. To the best of my knowledge, death occurred at the time, date and place and due,..22a
<br />to the cause(s) stated.(Signature & Title) SIGNATURE AUTHENTICATED
<br />v ; JOSEPH D NAGAN DO
<br />On the basis of examination and/or irnestigation, in my opinion death occurred
<br />as at the time, date and place and due to the cause(s) stated. (Signature & Title)
<br />v o
<br />e , 21b. DATE SIGNED (Mo/Day/Yr)
<br />0 > December 21, 2018
<br />21c. HOUR OF DEATH
<br />17:31
<br />a 22b. DATE SIGNED (Mo/Day/Yr)
<br />0 IL
<br />rt
<br />22c. HOUR OF DEATH
<br />Ca , 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
<br />(Type or Print)
<br />m o 22d. PRONOUNCED DEAD (Mo/Day/Yr)
<br />22e. PRONOUNCED DEAD AT (Hour)
<br />23a. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER) (Type or Print)
<br />Joseph D Nagan DO 1800 W Charleston Blvd Las Vegas, NV 89102
<br />23b. LICENSE NUMBER
<br />D02449
<br />24a. REGISTRAR (Signature) NANCY BARRY
<br />SIGNATURE AUTHENTICATED
<br />24b. DATE RECEIVED BY REGISTRAR
<br />(MolDay/Yr) December 21, 2018
<br />24c. DEATH DUE TO COMMUNICABLE DISEASE
<br />YES I♦ NO Lj
<br />25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).)
<br />PART I(a) Acute Hypoxic Respiratory Failure
<br />Interval between onset and death
<br />4 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b) Acute Spontaneous Subdural Hemorrhage
<br />Interval between onset and death
<br />6 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c) Warfarin Therapy
<br />Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(d)
<br />Interval between onset and death
<br />PART 11 OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not resulting in the underlying cause given in Part 1.
<br />26. AUTOPSY (Specf
<br />Yes or No)
<br />No
<br />27. WAS CASE
<br />REFERRED TO CORONER
<br />(Specify Yea or No) No
<br />28a. ACC., SUICIDE, HOM., UNDET.
<br />OR PENDING INVEST. (Spedy)
<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.D. No. CITY OR TOWN STATE
<br />LOCAL REGISTRAR
<br />VRS-Rev-20120523a
<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 the State Board of Health pursuant to NRS 440.175.
<br />DEC 2 7 2018
<br />istrar of Vital Statistic
<br />This Copy not valid unless prepared on engraved border displaying date, seal and signature of Registrar.
<br />SOUTHERN NEVADA HEALTH DISTRICT • P.O. Box 3902 • Las Vegas, NV 89127 • 702-759-1010 • Tax ID # 88-0151573
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<br />ANY ALTERATION OR ERASURE yolosrrIlIS CERTIFICATE
<br />
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