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HomeMy WebLinkAboutApplication Applicant 11/17/2023,city of Springfield Development & Public Works 225 Fifth Street Springfield, OR 97477 Land Division Tentative Plan Partition, Subdivision SPRINGFIELD 1k Application Type(Applicant: check one) Partition Tentative Pre -Submittal: ❑ Subdivision Tentative Pre -Submittal: ❑ Partition Tentative Submittal: ISubdivision Tentative Submittal: ❑ Required Project Information (Applicant: complete this section) Applicant Name: Don Horton Phone: (541) 517-3059 Company: Fax: Address: 780 S 5th St, Springfield, OR 97478 Applicant's Rep.: Andrew Strout Phone: (541) 746-0637 Company: Branch Engineering Inc Fax: Address: 310 5th St, Springfield, OR 97477 Property Owner: Don Horton Phone: (541) 517-3059 Company: Fax: Address: 780 S 5th St, Springfield, OR 97478 I ASSESSOR'S MAP NO: 17-02-34-42 TAX LOT NOS : 7400 Property Address: 120,122 & 124 65th Place Size of Property: 5,511 Acres Square Feet X❑ Proposed Name of Subdivision: Description of If you are filling in this form by hand, please attach your proposal description to this application. Pro osal: Middle Housing Division Existing Use: Residential # of Lots Parcels: 3 Total acreage of parcels/ 0.13 acres /N/A proposed # 3 allowabl ensit Dwell Units .Signatures: Please sign and print your name and date in thea ro date box on the next Uppe. Required - -complete Associated Applications: Signs: Pre -Sub Case No.: Date: Reviewed b_: Case No.: Date: Reviewed by: Application Fee: $ Technical Fee: $ Postage Fee: $ y(� (TOTAL FEES: $ PROJECT NUMBER: 'n—;o b—ctw- q ! — Revised 1/7/14 kl 1 of 10 Owner Signatures This application form is used for both the required pre -submittal meeting and subsequent complete application submittal. Owner signatures are required at both stages in the application process. An application without the Owner's original signature will not be accepted. Pre -Submittal The undersigned acknowledges that the information in this application is correct and accurate for scheduling of the Pre- Submittal Meeting. If the applicant is not the owner, the owner hereby grants permission for the applicant to act in his/her behalf. I/we do hereby acknowledge that I/we are legally responsible for all statutory timelines, information, requests and requirements conveyed to my representative. Owner: Signature Print Submittal Date: I represent this application to be complete for submittal to the City. Consistent with the completeness check performed on this application at the Pre -Submittal Meeting, I affirm the information identified by the City as necessary for processing the application is provided herein or the information will not be provided if not otherwise contained within the submittal, and the City may begin processing the application with the information as submitted. This statement serves as written notice pursuant to the requirements of ORS 227.178 pertaining to a complete application. Owner: +,.►�- -i Date: 1 1 '7 .- S u re - -- =o n Print Revised 1/7/14 kl 2 of 10 Land Division Tentative Application Process 1. Applicant Submits a Land Division Tentative Application for Pre -Submittal • The application must conform to the Land Division Tentative Submittal Requirements Checklist on pages 4-6 of this application packet. • A pre -submittal meeting to discuss completeness is mandatory, and pre -submittal meetings are conducted every Tuesday and Friday, from 10:00 am - noon. • Planning Division staff strives to conduct pre -submittal meetings within five to seven working days of receiving an application. 2. Applicant and the City Conduct the Pre -Submittal Meeting • The applicant, owner, and design team are strongly encouraged to attend the pre - submittal meeting. • The meeting is held with representatives from Public Works Engineering and Transportation, Community Services (Building), Fire Marshall's office, and the Planning Division and is scheduled for 30 to 60 minutes. • The Planner provides the applicant with a Pre -Submittal Checklist specifying the items required to make the application complete if it is not already complete, and the applicant has 180 days submit a complete application to the City. 3. Applicant Submits a Complete Application, City Staff Review the Application and Issue a Decision • A complete application must conform to the Land Division Tentative Submittal Requirements Checklist on pages 4-6 of this application packet. ® A Type II decision, made after public notice, but without a public hearing, unless appealed, is issued within 120 days of submittal of a complete application. • Mailed notice is provided to property owners and occupants within 300 feet of the property being reviewed and to any applicable neighborhood association. In addition, the applicant must post one sign, provided by the City, on the subject property. • There is a 14 -day public comment period, starting on the date notice is mailed. • Applications are distributed to the Development Review Committee, and their comments are incorporated into a decision that addresses all applicable approval criteria and/or development standards, as well as any written comments from those given notice. • Applications may be approved, approved with conditions, or denied. • At the applicant's request, the Planner can provide a copy of the draft land use decision prior to issuing the final land use decision. • The City mails the applicant and any party of standing a copy of the decision, which is effective on the day it is mailed. • The decision issued is the final decision of the City but may be appealed within 15 calendar days to the Planning Commission or Hearings Official. Revised 1/7/14 kl 3 of 10 Land Division Tentative Submittal Requirements Checklist NOTE: • ALL of the following items MUST be submitted for BOTH Pre -Submittal and Submittal. • If you feel an item on the list below does not apply to your specific application, please state the reason why and attach the explanation to this form. ❑X Application Fee - refer to the Development Code Fee Schedule for the appropriate fee calculation formula. A copy of the fee schedule is available at the Development & Public Works Department. Any applicable application, technology, and postage fees are collected at the pre -submittal and submittal stages. ❑X Land Division Tentative Application Form Narrative explaining the purpose of the proposed development, the existing use of the property, and any additional information that may have a bearing in determining the action to be taken. Density - list the size of property (acres), maximum allowable density and the density proposed. N Copy of the Deed N/A❑ Copy of a Preliminary Title Report issued within the past 30 days documenting ownership and listing all encumbrances. N/A ❑ Copy of the Land Division Plan Reduced to 81/2"x 11", which will be mailed as part of the required neighboring property notification packet. N/A❑ Right -of -Way Approach Permit Application provided where the property has frontage on an Oregon Department of Transportation (ODOT) facility. N/A❑ Three (3) Copies of the Stormwater Management System Study with Completed Stormwater Scoping Sheet Attached - The plan, supporting calculations, and documentation must be consistent with the Engineering Design Standards and Procedures Manual. N/A[:] Three (3) Copies of the Traffic Impact Study prepared by a Traffic Engineer in accordance with SDC 4.2-105 A.4. Traffic Impact Studies (TIS) allow the City to analyze and evaluate the traffic impacts and mitigation of a development on the City's transportation system. In general, a TIS must explain how the traffic from a given development affects the transportation system in terms of safety, traffic operations, access and mobility, and immediate and adjoining street systems. A TIS must also address, if needed, City, metro plan and state land use and transportation policies and objectives. X❑ Four (4) Copies of the Following Plan Sets for Pre -Submittal OR Three (3) Copies of the Following Plan Sets: ❑ All of the following plans must include the scale appropriate to the area involved and sufficient to show detail of the plan and related data, north arrow, and date of preparation. ❑ All plan sets must be folded to 81/2" by 11" and bound by rubber bands. a. Site Assessment of Existing Conditions N/A ❑ Prepared by an Oregon licensed Landscape Architect or Engineer Revised 1/7/14 kl 4 of 10 N/A ❑ Vicinity Map N/A❑ The name, location, and dimensions of all existing site features including buildings, curb cuts, trees, and impervious surface areas, clearly indicating what is remaining and what is being removed. For existing structures to remain, also indicate present use and required setbacks from proposed property lines. N/A❑ The name, location, dimensions, direction of flow and top of bank of all watercourses and required riparian setback that are shown on the Water Quality Limited Watercourse Map on file in the Development & Public Works Department N/A❑ The 100 -year floodplain and floodway boundaries on the site, as specified in the latest adopted FEMA Flood Insurance Rate Maps or FEMA approved Letter of Map Amendment or Letter of Map Revision N/A❑ The Time of Travel Zones, as specified in SDC 3.3-200 and delineated on the Wellhead Protection Areas Map on file in the Development & Public Works Department N/A ❑ Physical features including, but not limited to trees 5" in diameter or greater when measured 4 1/2 feet above the ground, significant clusters of trees and shrubs, riparian areas, wetlands and rock outcroppings N/P ] Soil types and water table information as mapped and specified in the Soils Survey of Lane County. A Geotechnical Report prepared by an Engineer must be submitted concurrently if the Soils Survey indicates the proposed development area has unstable soils and/or a high water table b. Land Division Tentative Plan ❑X Prepared by an Oregon licensed Land Surveyor N/A❑ City boundaries, the Urban Growth Boundary, and any special service district boundaries or railroad right-of-way which cross or abut the proposed land division ❑X Location and width of all existing and proposed easements on and abutting the proposed land division ❑X Boundaries of entire area owned by the property owner, of which the proposed land division is a part, as well as dimensions and size of each parcel and the approximate dimensions of each building site indicating the top and toe of cut and fill slopes to scale ® Location and type of existing and proposed street lighting, including type, height, and area of illumination X❑ Location, widths, conditions, and names of all existing and proposed streets, alleys, dedications or other right-of-ways within or adjacent to the proposed land division. Proposed streets should also include approximate radius of curves and grades and relationship to any projected streets as shown on the Metro Plan, TransPlan, Conceptual Development Plan, or Conceptual Local Street Map. N/A ❑ Location of existing and required traffic control devices, fire hydrants, power poles, transformers, neighborhood mailbox units and similar public facilities X❑ Location and dimensions of existing and proposed driveways N/A ❑ Location of existing and proposed transit facilities ❑X Location and width of all existing and proposed sidewalks, sidewalk ramps, pedestrian access ways and bike trails N/A ❑ Location, size and type of plantings and street trees in any required planter strip Revised 1/7/14 kl 5 of 10 N/A ❑ Location and size of existing and proposed utilities on and adjacent to the site including sanitary sewer mains, stormwater management systems, water mains, power, gas, telephone, and cable TV. Indicate the proposed connection points N/A❑ The locations of all areas to be dedicated or reserved for public use, with the purpose, condition or limitations of the reservations clearly indicated N/A❑ Future Development Plan where phasing or large lots/parcels are proposed as specified in SDC 5.12-120 E. c. Stormwater Management Plan N/A ❑ Prepared by an Oregon licensed Civil Engineer N/A ❑ Planting plan prepared by an Oregon licensed Landscape Architect where plants are proposed as part of the stormwater management system N/A ❑ Roof drainage patterns and discharge locations N/A ❑ Pervious and impervious area drainage patterns N/A ❑ The size and location of stormwater management systems components, including but not limited to: drain lines, catch basins, dry wells and/or detention ponds; stormwater quality measures; and natural drainageways to be retained N/A ❑ Existing and proposed spot elevations and contours lines drawn at 1 foot intervals (for land with a slope over 10 percent, the contour lines may be at 5 foot intervals) N/A ❑ Amount of proposed cut and fill N/A❑ Additional Materials That May be Required IT IS THE APPLICANT'S RESPONSIBILITY TO DETERMINE IF ADDITIONAL STANDARDS/APPLICATIONS APPLY TO THE PROPOSED DEVELOPMENT. THE APPLICANT SHOULD CONSIDER UTILIZING PRE -DEVELOPMENT MEETINGS AS DISCUSSED IN SDC 5.1-120: ❑ Proposed deed restrictions and a draft of any Homeowner's Association Agreement ❑ Additional plans and documentation for submittal of a Cluster Subdivision proposal as specified in SDC 3.2-230 ❑ Riparian Area Protection Report for properties located within 150 feet of the top of bank of any Water Quality Limited Watercourses (WQLW) or within 100 feet of the top of bank of any direct tributaries of WQLW ❑ A Geotechnical Report prepared by an engineer must be submitted concurrently if there are unstable soils and/or a high water table present ❑ Where the development area is within an overlay district, address the additional standards of the overlay district ❑ If five or more trees are proposed to be removed, a Tree Felling Permit as specified in SDC 5.19-100 ❑ A wetland delineation approved by the Oregon Division of State Lands must be submitted concurrently where there is a wetland on the property ❑ Any required federal or state permit must be submitted concurrently or evidence the permit application has been submitted for review ❑ Where any grading, filling or excavating is proposed with the development, a Land and Drainage Alteration permit must be submitted prior to development Revised 1/7/14 ki 6 of 10 ❑ Where applicable, any Discretionary Use or Variance as specified in SDC 5.9-100 and 5.21-100 ❑ An Annexation application, as specified in SDC 5.7-100, where a development is proposed outside of the city limits but within the City's urban service area and can be served by sanitary sewer ❑ All public improvements proposed to be installed and to include the approximate time of installation and method of financing Revised 1/7/14 kl 7 of 10 THIS APPLICATION IS: ® COMPLETE FOR PROCESSING ❑ INCOMPLETE AND NEEDS MISSING INFORMATION NOTED ABOVE 01&a r b,A 3, 2023 City Planner Date This is not a decision on your application. Springfield Development Code Section 5.4-105 and Oregon Revised Statutes 227.178 require the City take final action on a limited land use decision within 120 days after the application is deemed complete. The 120 -day processing period for this application begins when all the missing information is submitted or when you request that the City proceed without the information. You must indicate by either signing this form or by submitting a written response to the City within seven days of the date of this form asserting your intentions regarding the provision of the missing information. If you indicate herein or in your written response that the missing information will be submitted, then you have 180 days from the date the application was submitted for Pre -Submittal Review to provide the City with the missing information. If you refuse to submit the missing information, then upon receipt of the full application packet and processing fee, the City will deem the application complete for purposes of starting the 120 -day clock and begin processing the application. No new information may be submitted after the start of the 120 -day period unless accompanied by a request for an extension of the 120 -day processing time. Upon receipt of a request for extension, the City may extend the 120 -day period for a reasonable period of time. The City may also require additional fees if the new information is submitted after the Notification to Surrounding Property Owners is sent out and a second notification is required or if the new information substantially affects the application proposal and additional review is required. I, the owner/applicant, intend to submit all missing items indicated herein to the City within the 180 -day timeline. icant's Signature Revised 10/25/07 November 17, 2023 PROJECT NARRATIVE 120, 122, 124 65— PLACE MIDDLE HOUSING DIVISION - TRIPLEX Branch Engineering Inc. Project No. 23-415 Branch ENGINEERING= Since 1977 The site is located at 120, 122 and 124 651 Place (TM: 17-02-34-42-07400). The site is fully developed as a triplex (Building Permit Number 811-23-001719-DWL) through the City of Springfield's Middle Housing Section of the Springfield's Development Code (SDC). This application intends to divide the lot into three separate parcels each with a dwelling from the triplex. Separate utilities connect to each of the dwellings in the triplex. The exception to this is the stormwater system on-site. Due to the triplex being one structure, its drainage is collected in a joint soakage trench and infiltrated on-site. All shared driveway area and the stormwater system are encompassed by easements. Should any additional easements be required for water, electric, fiber/telecommunication or sanitary sewer, they will be included on the final plat. EUGENE -SPRINGFIELD 310 Sth Street, Springfield, OR 97477 1 p: 541 .746.0637 1 www.branchengineering.com AFTER RECORDING RETURN TO: Lane County Surveyor's Office 3050 N. Delta Hwy, Eugene, OR 97408 PLAT DOCUMENT # Lane County Clerk 2019-050948 Lane County Deeds and Records II{flflll11111lllllllllfil{II{��if1111111i1111111 $1$700 01818551201900509480010015 11/08/2019 09:14:11 AM RPR -SUED Cnt=1 Pgs=1 Stn=1 CASHIER 05 $5.00 $100.00 $10.00 $11.00 $61.00 This document is a SUBDIVISION: KYLEE MEADOWS Owner: Don M.Horton Dedicatee: -Springfield Twp. lis Rng. 02W Sec. 34 LANE COUNTY DEEDS &RECORDS 8 -Lots 2 - Stickers (Plat Pages) 2 - Reserved Numbers --T— m g z a C $ pA h � p O Em > n� "I 0 0 V �$ W = Z N z 3.^i I2 � s„ g o I W a Wi I WO �� BFti 33>E Op'28 o W 1 I w r bi Up WU �z � 0 oo� 0�' CiWwtpY•r Clef)� z $I — moo, e, g ti � ac T�Gi g a t yr L •'r0, O1 (cXrJl�w-eo-lH�er.aoo�i g � 2 - - 3)v7d 8199- 1M 00'b 00'b 0 - t i $ pA h I I"1 r "I A a A T I2 � s„ I I WO �� BFti 33>E Op'28 1 I w r bi r. ,;Ww Artmv s rlpr�anW rs'Zg Of'" iN a2 r6 y 2s nm6~ 118' 1. �CW — i $ pA h r "I 33U £ilgIng a A T a t W CQ CD CS W 4 V N U43 � 0 R K LILJ W v v 8Y $vc8 �J I Lj W 6 � 2 Wig � kit 121 a � ![all � �q, hig � �i"RIX9 Val� Of S'n i lin w� mM� o�tiWm it W �$Mala �� a$ leg Mi 1; x �a tvj R�' z A 3Jl� 3111 ball Rif I 61011M b-491 fih� n CASCADE TITLE CO. TITLE NO. 0289985 ESCROW NO. EU l 15-1423Lf— TAX ACCT. NO. 0141430 MAP/TAX LOT NO, 17023442944500 GRANTOR THE HINSHAW FAMILY TRUST GRANTEE DON M H.ORTON 780 SOUTH 57TH STREET SPRINGFIELD, OR 97478 Until a change is requested all tax statements shall be sent to the following address: ***SAME AS GRANTEE*** Lane County Clerk �j Lane County Deeds and Records 2017-016132 11111 0164 I $62.00 1295201700161320049 04/03/2017 RPR—DEED Cnt=1 Stn_9 CASHIER 11 QZ'00,58 PM $20.00 $11.00 $21.00 $10.00 After recording return to: CASCADE TITLE CO. 811 WILLAMETTE EUGENE, OR 97401 WARRANTY DEED -- STATUTORY FORM TERRY L. SMITH and SHARON L. SMITH, SUCCESSOR TRUSTEES of THE HINSHAW FAMILY TRUST, Grantor, conveys and warrants to DON M HORTON, Grantee, the following described real property free of encumbrances except as specifically set forth herein: SEE EXHIBIT A WHICH IS MADE A PART HEREOF 13Y THIS REFERENCE BEFORE SIGNING OR ACCEPTING THIS INSTRUMENT, THE PERSON TRANSFERRING FEE TITLE SHOULD INQUIRE ABOUT THE PERSON'S RIGHTS, IF ANY, UNDER ORS 195.300, 19.5.301 AND 195.305 TO 195.336 AND SECTIONS 5 TO 11, CHAPTER 424, OREGON LAWS 2007, AND SECTIONS 2 TO 9 AND 17, CHAPTER 855, OREGON LAWS 2009, AND SECTIONS 2 TO 7, CHAPTER 8, OREGON LAWS 2010. THIS INSTRUMENT DOES NOT ALLOYS' USE OF THE PROPERTY DESCRIBED IN THIS INSTRUMENT IN VIOLATION OF APPLICABLE LAND USE LAWS AND REGULATIONS. BEFORE SIGNING OR ACCEPTING THIS INSTRUMENT, THE PERSON ACQUIRING FEE TITLE TO THE PROPERTY SHOULD CHECK WITH THE APPROPRIATE CITY OR COUNTY PLANNING DEPARTMENT TO VERIFY THAT THE UNIT OF LAND BEING TRANSFERRED IS A LAWFULLY ESTABLISHED LOT OR PARCEL, AS DEFINED 1N ORS 92.010 OR 215.010, TO VERIFY THE APPROVED USES OF THE LOT OR PARCEL, TO DETERMINE ANY LIMITS ON LAWSUITS AGAINST FARMING OR FOREST PRACTICES, AS DEFINED IN ORS 30.930, AND TO INQUIRE ABOUT THE RIGHTS OF NEIGHBORING PROPERTY OWNERS, 1F ANY, UNDER ORS 195.300, 195.301 AND 195.305 TO 195.336 AND SECTIONS 5 TO 11, CHAPTER 424, OREGON LAWS 2007, AND SECTIONS 2 TO 9 AND 17, CHAPTER 855, OREGON LAWS 2009, AND SECTIONS 2 TO 7, CHAPTER 8, OREGON LAWS 2010. Except the following enctimbrances: Covenants, Conditions, Restrictions and Easements of record. The true consideration for this conveyance is $178,333.00. WRD LTR Dated this �,-3670'1 day of THE HINSHAW FAMILY UST B Y: 4-RRR)rlL, S ITH, UCCESSO t TRUSTEE BSC sic HARON L. SMITH, SUCCESSOR TRUSTEE State of Ha it County of This instrument was acknowledged before me on 3 ��fl , ?017 by TERRY L. SMITH and SHARON L. SMITH, SUCCESSOR TRUSTEES of THE Hi SHAW FAMILY TRUST. 94? -- k ry Public rpy WAl ) My commission expires Doc. Date: # Pages: `r' PIotary Name: ircuit Doc. Description: re aiet.gna pTAr1y.9tA �•. No. 07-63 WRD LTR F / ;�x �jOTAgrf��: No. 07-63 ,O F ,N Exhibit "A" The South 280 feet of the following described property: Beginning at a point on the North right of way line of the McKenzie Highway, South 64.4 feet and South 89' 44' East 104.4 feet fi-om the Northwest corner of the Thos. I Maynard Donation Land Claim No. 44, in Section 34, Township 17 South, Range 2 West of the Willamette Meridian; thence North 836.2 feet; thence South 86° 12' West 162.6 feet; thence North 840 02' West 22.7 feet; thence South 826.9 feet to the North right of way line; thence South 890 44' East along said right of way line 184.8 Peet to the point of beginning, in Section 34, in Lane County, Oregon. LEGAL(CF) OREGONA t 502796 3. Sax 9JIF)) 4a. 111ige111,11e31e10011r 4b. oder 1 Yeor 4c, or 1 5. Sodal Saeutlry Number a. %' u Y ,oar ciao tAnuts. 549-58 -3462 T+an=- ''•'�.. MNM. Femax a 7 I I 8 9 -12th grade no CUP.10=51 7. BIr[hdalal wrvl on. nuthplaceKAPFromercausrf Bb. (san«rotstaftinvi) ..-12tnCaEdade October 192..E North Bend 10. Wee Diptienl of H!spwtk origin? (w. or ftevm sp.*4 11. Dowdont'a �pc�ta) •. 12.. Was D"00qq) Ever In D.Yes . v h* CB U.S•Arined Forcos4 ffNo 12. Residence: Number ond81root p.wWesEemeesgap.M..a) 14. ClryRbwrt 205 s. 54th Street, S ce 6 S ring4leld 15. Residence County. 16. State or Foralgn Country 17. Zip Code +4 18. 'Inside.City Llmite9 8• No •. 0 Unknown ' Lane Oxea+�n . W Yes D. Q. Madtak smma at TWO@ 9� T�ess974 26. s�laCka 1raiiMW aAkimrd.n,) V22 Learo xi. Usual Occupation ptitrateMwofwoendoes du*gnonet-co"Me. 0oNOT USE •nsTtaEy 22. I(IndofBustnessAndualry(oor+orUSE eoMVlrnluME) Homemaker own Game 23. Fathor'sName !FlnrMldele,Lost, sulasf 24. Mothers�1ew.FriortoFllstMardageerrsawdm.wo William • Bdwin Fisher ' Ethel Rosalee Howard .25. Informant's Name J26. TalephonaNumbar 27. RelaliontoDecedent24. Mailing Address (m-israse.et.awramsutaas+q Sharon Smith 541-747-9257 Daughter.• 05 S.. 54th St.. SPC#6 SPringf1e.d, OR97476 •• .Fa. PtwWof.7salh 30. My Name Bos ital Mn tient McKenzie Wallamette Xed cal Ce'ntet n 31. Location of Death lone asar..r.i 32 CliyRnwrl or LoWo f Death 33. Stale $4. Zip Code +4 1460 G Street 5 ran iel OR... 97477 35. MEtiufdcSC;spasl7ion as. PWOeotOtepoNliohlwmadaansisry.�vnii:le�voreow'ep.ol 3T. LOCalbn Burial S rin said Xemorsal Gail S an ie1d, Oregon 26. Nam° and Complete Address of Funeral Facility (rnrre.ra w..i ayrre.n sut.:as.e) SDrinrrfieid Xemorial Pun Boma 7305 a1 Xain St.' S rain field, 'OR 97478 36. Date of DlsposRbnomwwrvl 40. n 1 Dlroctoes a 41. OR Uconea Number ► :co-�s36 42. Regletrar's n¢lura 4 Date•ReeelvadproeiooY,jtil 44, Localnoi�tftl�r`; 101.• UU UUit 4 45. u ondmenl 4a. Wero aulopsytinamgs avallable tocomptela the cause of dealh7. 49, Death D Yes D No GAUSiFOF iOFATH ace lesuuakaa sod etriltnptos.) er the choir or events .diseases, in)udta; Oreomplke911ans - the tf ecUy eaea0d the death, • Do NOT ENTER TERMINW. EVENTS Allah . 'Approk)met@ int@rve1:'. ardiac arrest, respiratorywrest or vantdWter gbdltation wllhcvl ahowlnp Iho a0olagV. DO NOTABBREVIATE. r l disease or condition IMMEDIATE CAUSE •L Onset to Death rosulttng In death-!tially list eondilkona. If any, Due to (er as a consequence cryto the cause tlelod on Ilno o. b. U THEUNDERLYINGeonaegtwru:e oh �!•LAST (tllaaeso orlMury ted theQuantarosullln Ing Due b (eras ° cauoquence oilJr er d' but nag resulting in tEhou-�drlyllll cause elven N l _ .._.-. ,,, ...i„ry re,Q.• bee+danl's he,* aoMWagen ane.recto.... rw.t t evrte.w� ens. ?+s •e) 1 urn6 woodad mea) 3a. In)ury at work? Below O Yna D No D Unknown tit. C7Ira eartiabrinhrry. saeciy. .. .. ❑ PasaenQor O Pedestrian Ph R CertifJer -• w,�an.erailer-7e - 77!! edF.)tarrlktar -l7noswrled 81 the0". date, and place, and due t69} AmendmentORIGINAL • VITAL RECORDS COPY THIS IS A AT H E F REGISTERED 07 REPROOUCT(ON OF THE DOCUMENT OFFICIALLY �. 4 ED AT THE OFFICE OF THE LANE COUNTY AEGISTRAq, 0 MA f �Rt� r -n t crrc-'