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<br />
<br />
<br />TYPE
<br />OR PRlNT
<br />IN
<br />PERMANENT
<br />INK
<br />FOR
<br />INSTRUCnONS
<br />SEE
<br />HANOBOOK
<br />
<br />IF OEATH
<br />OCC1)RRED IN
<br />INSTITUTION.
<br />SE" HAND600K
<br />REGARDING
<br />COMPLETION OF
<br />RESID"NC" ITEMS
<br />
<br />
<br />~
<br />
<br />
<br />CONDITIONS
<br />IF ANY
<br />WHICH GAV"
<br />RISE TO
<br />IMMEDIAT"
<br />CAUSE
<br />STATING THE
<br />UNO"RLVING
<br />CAUSE LAST
<br />
<br />L+
<br />
<br />
<br />~~
<br />'b
<br />~-~-/'
<br />
<br />/0([ NON-RES
<br />
<br />STATE OF WYOMING
<br />
<br />200604912
<br />
<br />DIVISION OF HEALTH AND MEDICAL $eA"'IC~$
<br />
<br />CERTIFICA TE OF DEATH
<br />
<br />LOCAL FILE NUMBER
<br />O"CIOO"NT -NAME FIRST MIDDLE
<br />
<br />S"X
<br />
<br />STATE FILE NUMBER
<br />DA r E OF DI;:A TH (Mil.. [)41Y. y,..;
<br />
<br />
<br />LAST
<br />
<br />1.
<br />
<br />WALTER
<br />
<br />~ Se tember 9.1985
<br />DA.TE OF BIRfH (M,!.,1.J"y, )"r,}
<br />
<br />BECKER
<br />
<br />2. Male
<br />UN()EH 1 DAY
<br />
<br />RACE: .,(a.y., While,Al~Gk, American OAtC1:IN Of~ OtSCEN't (e.g. Italian, Mexican, AGE La::;t Bhthtlay
<br />Indian, etc.) (.~'p"ci/..",!J German, Puoflo Rican, Engli:!;ih, Cuban, etc.) (Yrs.)
<br />4a. Whi te ~t,i'Y) 5a_ 75
<br />~'"'DE:Ar,w.j'o::;p;tall)l' Omer Institution.Na.me (If;;:nl
<br />;It er/b-B,. !(ifll' J/f't?~t lI"d ftuMher)
<br />
<br />MOS.
<br />
<br />6. .c.l:L1
<br />
<br />
<br />8. Nebraska USA
<br />SOCIAL SECURITY NUMBER
<br />
<br />Imqt.i~~
<br />
<br />MARRIf.D, NEVER MAPiHIED,
<br />WIDOWED, DlVORCEO !-'po<i'vl
<br />
<br />10. Marri.ed 11.Dorothy Voss
<br />
<br />USUAL OCCUPA T1()N((Ti:,~~ 1e,~4 lif "'ork do".. dU";"R mOJt 0/
<br />umrlti"x lifl!. c""" If rll"tn.JJ
<br />
<br />7d. ---.Carb.DIl...-..._
<br />WAS LJECF-DFNT FVEFi IN U,$
<br />ARM(D r'OHC(S?
<br />~t'fv Ji:j'O'S")
<br />KINDOF6USINESSORIND'Lis'TRY .-----
<br />
<br />
<br />13.507-48-6823
<br />R~SIO~NCE.STATE COUNTY
<br />
<br />14a. Farmer
<br />CiTy~ TOwN OR LOCA TlON
<br />
<br />" 14~:_~JigIJ~llJ ture
<br />STREET AND NuMBER
<br />
<br />
<br />
<br />15a.Nebraska 15b. Hall
<br />
<br />1 c. Grand Island
<br />LAST
<br />
<br />1 704 S
<br />FIRST
<br />
<br />ne
<br />MIUDLE:.
<br />
<br />FATHER-NAME
<br />
<br />FIRST
<br />
<br />MIDDL~
<br />
<br />16. Au ust
<br />INFORMANT NAME O:vP-B or PN.~tJ
<br />
<br />Becker
<br />MAII,ING AOORESS
<br />
<br />Emelia
<br />CITV OR TOWN
<br />
<br />Ewoldt
<br />SlATE::
<br />
<br />ZIP
<br />
<br />18b. 1 704 S
<br />
<br />Blaine
<br />
<br />
<br />~"";TAH::
<br />
<br />IJay, Yr,)
<br />
<br />CEMETERY OR CRf:MATOHY "',. NAME
<br />
<br />CITY OR TOWN
<br />
<br />1. Grand Island Cemeter
<br />NuMBl::R NAME OF f.ACIU1v
<br />
<br />19d. Grand Isl_9..DJJ,. NE,
<br />NUMBER ADDRESS OF FACILITY
<br />
<br />8 20c. Box 1928
<br />
<br />Rawlins
<br />
<br />WY
<br />
<br />~
<br />~
<br />it
<br />.0
<br />1i'"
<br />EW
<br />OZ
<br />uO
<br />1:[5
<br />ou
<br />>--
<br />
<br />22a.Onll"lf! basiS or ~!xarninali(Jn andlm investi~hltion, in my opInion G(',Jth OCCUrllXj ~1t tile 11/1\(.'.
<br />date and place and duc to !he cause(s) s1ateo.
<br />
<br />(\;":IIIliturl! a1lJ TII/~) ....
<br />DATE SIGNED (Mn.. Va,V. Yr.)
<br />
<br />HOUR OF OtA TH
<br />
<br />22b.
<br />PRONOUNCED DEAD (Mo" OJ''''', rr.)
<br />
<br />22e.
<br />PRONOUNCETJ DE"i\() (IlOlH-)
<br />
<br />M
<br />
<br />22d. ON
<br />
<br />22e. AT
<br />
<br />M
<br />
<br />..B2.3OL.
<br />
<br />_"~"...',_~W,,_~_,
<br />..__.,-~-
<br />
<br />{
<br />
<br />JK~tk~::'
<br />
<br />t 1II]I'IV,I'llI.':Jveellul',',','I,I:II:',!I',I':;
<br />
<br />(0)
<br />-OUE 10. ORAs'"ACONSEOuENC" 0.,----
<br />
<br />I IIH!~'vdl fll!lwt'I"l ~II",I~: ,I"(! (11~,I:1'
<br />
<br />(e)
<br />PART OTHH~ SIGNIFICANT CONDITIONS-ConditIons COf1!rlbuling 10 of;!('lth but not fAlated 10 c~u!'>e oiven in PART! (al
<br />U
<br />
<br />AUTOPSy (.''p~cif.'1 Voj1.J
<br />Ql"NoJ
<br />
<br />
<br />ACC., SUICIO", HOM., UNDEr..
<br />OR PENDING INVEST. (Jp<<;tvl
<br />
<br />26. No
<br />DFSCRIRF /lOW INJURY OCCURRED
<br />
<br />DATE OF !NJUnV (MQ" D4Y, Yr.)
<br />
<br />HOC lR OF IN]LJR Y
<br />
<br />28a.
<br />INJURY AT WORK (.,,.<;tv Y..
<br />fW Nol
<br />
<br />:za_ .;-- 28e.
<br />
<br />PLACE OF INJ~Y- A1 homE!, farn'l, street, lac tory, ~}f1ice building,
<br />", ,~~ " ' etc. (SPf1riJyJ
<br />
<br />i28e.
<br />
<br />
<br />
<br />ST~eeT OR A,F.O. No.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />Da tc I s sued __.__:.~~pt._el!l_~~.~. ..?.i!.-.!2_~_~~__~
<br />
<br />THIS IS TO x:;IRTIFY thutthi's reproduction is a true copy of a record on file in
<br />Vital Recorcfs Services, Division of Health and Medical Services, Wyoflling Department
<br />of Health and ~ocial Services, Cheyenne, Wyoming.
<br />
<br />"/~.. ,.', \~.,\,,~:..
<br />If th do'~si,~l.~nt'b~ar a raised seal and the signature of the Deputy State
<br />: i s copy '>-'
<br />Registrar is not in RED, this is not an official certified copy.
<br />
<br />
<br />IMO
<br />awrence J. Cohen, M. D.
<br />5 tat e Reg j s tr a r
<br />
<br />Richard O. Hall
<br />Deputy State Registrar
<br />
<br />. ....._...'" _,~.!...._,_.!.....-..~.,,,,,,:,,,,,,-..:,_...",,~,:,,_-t-~~_,,,,.'!:_..,._..!'_,,_._,,,_~_~~_.":"""",:,,,,~_.!.._.,.,_!._~.....L
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