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Show CERTIFICATE Rl::GISTRAR'S No ci z ....X II: m 1. PLACE OF DEATH : A. COUNTY STATE OF NEVADA B. CITY. TOWN. OR LOCATION D. NAME OF HOSPITAL OR INSTITUTION E. IS PLACE 2. CLARK A. C. (If lIot ill ho.'pital, yi"e street address ) NEY DE CITY LIMITS? YES 3. NAME OF DECEASED (Type or Prill!) 7 . MARRIED .II NEVER MARRIED lOA . WIDOWED D I D DIVORCED D USUAL OCCUPATION (Uiv e kiwlofwork done during 'I1W $ t 0/ workilly1ijc, even if retired ) 12., CITIZEN OF WHAT COUNTRY? USA OPEFtA TOR-OWNER ER .IN U. S . ARMED yes, gzve war or dates service) CAUSE OF DEATH PART I. 16 . SOCIAL SEC . NO . I (Enter only one cause per DEATH WAS CAUSED BY: IMMEDIATE CAUSE 'f ' 't } DUE TO (s) ztW1tS, t any, w I ue C on d " gave rise to above cause (a), statin{J the underlying cuII'e la .t. . DUE TO (c) PART II . OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I (A) ACCIDENT HOMICIDE HOUT D D a .1n . p.n!. SUICIDE 20s. DESCRIBE HOW INJURY OCCURRED !.1 1ollth, Day, Year . INJURY OCCURRED WHILE AT NOT WHILE WORK AT WORK D D tJ PLACE OF INJURY (e. g., in or about fa rm, fa~·tory, street, office ,bldg., etc. ) 20F . CITY . TOWN. OR LOCATION ES.2'I.GJA.TED ....ON....... ~iJl]GiXfX>;~Ja1Ci~X(X«JG~if]6K .. COUNTY |
