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321�24�
<br />1. . T G NO.
<br />I- X70
<br />Local File Number
<br />ooFi. DECEDENTS Ast
<br />NAME Lyda..
<br />/ 4. SOCIAL SECURITY NUMBE'
<br />--) urstcscnv utrHEALTH D VISION AN SERVICE��� - _4q
<br />--I CENTER FOR HEALTH STATISTICS F1
<br />CERTIFICATE OF DEATH 136'
<br />State File Number
<br />Middle Last 2. SEX 13. DATE OF DEATH (Month, Day, Year)
<br />B SIGLER Female jJune 25, 2000
<br />T 5a. AGE -Lest BirdMey Sb. Under 1 Year So. Under 1 Day S. BIRTHPLACE (City and State or Forso 7. DATE OF BIRTH (Month, Day, Year)
<br />497 -52 -4584 rte) Moe. ;Days Haan iMks. &i o,
<br />S. WAS DECEDENT EVER iN as. PLACE OF DEATH (Gheck
<br />U.S. ARMED FORCES? TA' )CI ❑ EROuipetlmt DOA ❑Nursing Home Yes )oft
<br />I
<br />gb. FACILITY NAME (H not insefuliOn, give street arts number) _ I CITY, TOWN, OR LOC
<br />1 St. Charles Medical Center Bend
<br />2 100. DECEDENTS USUAL OCCUPATION tOb. KIND OF BUSINESSANDUSTRY 11. M
<br />(Give kind of wed dons dtalnp most d working Nte. N
<br />ngt�ranredl D
<br />3 Artist /Teacher University Wi
<br />4 138. RESIDENCE - STATE 13b. COUNTY 130, CITY, TOWN OR LOCATION 13d.1 orecion Bend
<br />5 130. INSIDE CRY 131. ZIP CODE 14. WAS DECEDENT OF HISPANIC ORIGIN? S. RACE Amet
<br />LIMITS? (Specify No or Yes - ff yes, spq& Cuban, Slack, White, a
<br />6 Mexican, Puerto Rican, etc.) m No ❑ Ves-
<br />�.rea ONO 97702 S White
<br />17. FATHER - NAME Wet middle lest 78. MOTHER NAME first middle maiden
<br />Joseph Burry Sylvia . Elliot
<br />20a. METHOD OF DISPOSITION ❑ Meuedeum . ' ' 20b. P PISPOSITION (NNW of eOsawely crematory
<br />❑ &nlal Cremation ❑ Iterrtaual frpRSwa Funeral Alternatives Crematc
<br />7 ❑ Donation ❑ Other (Specify)
<br />21a. SIGNATURE OF OREGON ,SF, LICENSEE (* 21b. OREGON LICENSE NO. . NAME„
<br />$ ACTING AS SU /OVLbsnaesJ
<br />s 3Z
<br />23. DA FILED , Day. Ypar) V i 'i�G
<br />®nit Home ❑ Other (Speci _
<br />)F DEATH ad. COUNTY OF DEATH
<br />ike-schutes
<br />w=ded 12. SPOUSE Married. Widowed)
<br />specify)
<br />Don W. Sigler
<br />AND NUMBER
<br />an, 1S. DECEDENTS EDUCATION
<br />- .(Specfy Only highe sf efe�
<br />Elm~Seary (0.12) � Coe(1-4 o
<br />r 5 +)
<br />I. INFORMANT - NAME and relationship to deceasec
<br />orothy Norton- Daughter
<br />Ic. LOCATION - City or Town, State
<br />Bend, Oregon
<br />D ZIP OF FACILITY.
<br />molds & Tabor Funeral
<br />I Irving,,�nd, OR-97701
<br />ncxn Gb101 MMr1'Li A♦�it IP - T
<br />III I��I
<br />1 D TO BE CdMk
<br />TIME OF DEATH iII4
<br />1a SATE
<br />1d1NCED DEAD (Monts, Day, Year, Hex)
<br />I 6:50 P I�illi
<br />M
<br />2g. To the beat of my M11at0. Rlace Yelp I .
<br />=i �O �u "iTnlhe tl sari i atigatlon, in my opinion death occurred
<br />m ttteNY, 1Slad a ar;d due to cite cause(e) and manner stated.
<br />(SW�eaxe) �!
<br />,. 30. DATE SIGNED (Month, Day, Year) ) 3. DATE SIGNED
<br />1? (Monts, Day. Year) COUNTY
<br />1334. NAME, TITLE, ADDRESS AND ZIP OF CERTIFIRWMEDICAL EXAMINER (Type or Print)
<br />14 Thomas Warlick M.D. 1501 NE Medical. Center Drive,_ Bend OR 97701
<br />CONDITIONS 35. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER fType 0r pini
<br />IF ANY
<br />WHICH GAVE
<br />RISE TO • 38, IMMEDIATE CAUU${'E�((ENNTTERR Oft t`YY CI E CAUSE PER LINE FOR � (ate), (b�), AND S( /c))..)yDoo not ten8terr�mode Of 0) irg, e.g. Cardiac or Respiratory Amest. Interval between onset
<br />ST CAUS .'PART(a) 1M -k 71 k0 SCLb(W\� �- MIIl0"V{ J�-L%\,.WL D`�iJr a -
<br />UNDERLYING DUE TO, OR AS A CONSEQUENCE OF: InternTal between onset
<br />CAUSE LAST ; and death
<br />1 (b
<br />�f► DUE TO, OR AS A CONSEOUENCE OF: interval between onset
<br />and death
<br />o)
<br />-PART OTHER SIGNIFICANT CONDITIONS - 37. Did tobacco use contribute 38. AUTOPSY canaidered
<br />II 3g: a YES were A
<br />Conditions contributing to death but not resoling In the underlying cause given in PART I. to the death? in Oetetmklin9 crease of death?
<br />15 ❑ Yea ❑ Pmbabfy
<br />❑ *the WVM 0 Yes VIVO ❑ Yes ❑ No ❑ WA
<br />16 40. MANNER OF DEATH 41a. DATE OF INJURY 41b. TIME OF 41c. INJURY 41d. DESCRIBE HOW INJURY OCCURRED
<br />17 �Nahi ❑ nvesbg Ibn (Monts. Day. Year) INJURY AT WORK?
<br />❑ Accident ter
<br />❑Undetermined M ❑ Yes ❑ No
<br />❑ Suicide Manner
<br />❑ Homicide ❑ Legal 410• PLACE OF INJURY - At home, farm, air", factory, office 411. LOCATION (Street and Number or Rural Route Number, City or Town. Slate)
<br />building, etc. (Specify)
<br />CAUSE OF DEATH Other
<br />Intervention
<br />NSTRUCTI RESERVED FOR REGISTRAR'S USE
<br />ON REVERSE SIDE
<br />OF GREEN AND
<br />POW COPY
<br />u "��`�11 t
<br />�llht�p�+l
<br />JO
<br />ORIGINAL VITAL STATISTICS COPY
<br />45 -2 -Rev
<br />F /f
<br />-
<br />{�i
<br />THIS IS A TRUE AND EXACT REPRODUCTION OF THE DOCUMENT OFFICIALLY',
<br />REGISTERED AT THE OFFICE OF THE DESCHUTES COUNTY REGISTRAR.
<br />DANIEL W. PEDDYCORD
<br />WA
<br />DATE ISSUED:
<br />COUNTY REGISTRAR
<br />DESCHUTES COUNTY, OREGON
<br />0
<br />rrAkjJ;.
<br />„ ,.
<br />THIS COPY NOT VALID WITHOUT INTAGLIO STATE SEAL AND BORDER.
<br />_
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