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STATE Or COLD ADO
<br />DELAYED
<br />STATE OF COLORADO STATE FILE NUMBER
<br />CERTIFICATE OF DEATH
<br />R- 73643
<br />153 -58 -2869 23
<br />8. WAS OE EDENT EVER IN IM. PLACE Oi
<br />U.S. ARMED FORCE
<br />O Yea NO HOSPITAL: U
<br />9b. FACILITY NAME Ill not institution. 9.ve street
<br />Mary McKinney Mine
<br />10a. DECEDENT$ USUAL OCCUPATION
<br />(Give kind of work done durfn9 moslof worlds
<br />iM not use retired.)
<br />Painter
<br />13a. RESIDENCE -STATE 13b. COUNTY
<br />Colorado E1 Paso
<br />Rye. I 80907
<br />11. PAT HER -NAME (First, Af dtf t, Last)
<br />Donald Samuel Tease
<br />20a. METHOD OF DISPOSITION
<br />Q[Burial ❑ Cremation O Removal from State
<br />O Donation ❑ Other(Specify)
<br />VAT I: U, mrs" r. CIHI r1PLAOe It:rry and We,. w nor.,(
<br />(Month. Day. Year) Counlryl
<br />ig. 2, 1962 Philadelphia, PA
<br />9d.
<br />louse painti n q Married Lisa Montgomery
<br />13c CITY, TOWN, OR LOCATION 13d, STREET AND NUMBER
<br />Colorado Springs 4750 Rusina Rd., #405
<br />:DENT OF HISPANIC ORIGIN? 15. RACE: American Indian,
<br />16. DECEDENTS EDUCATION (Specify only highest
<br />o w Yes - If Yes, specify Cuban. Stack, While, etc. (Specfy) 0.6. compNfed) Elem. -'Y w secondary
<br />u.no Rican, etc! (01h -9h f 2) College (13 through 16 w 17 +)
<br />(es White
<br />11
<br />18. M -NA n4 Middi., Lost (Maiden Name)1 I 1 O* INFOR AANT-NAME and relationship to deco
<br />Janet Aileen Brown Janet Kunz -- Mother
<br />200. PLACE OF DISPOSITION (Name of cemagry, cre story, or 20c. LOCATION - City or Town, State
<br />other Place)
<br />Mary McKinney Mine Anaconda, near Cripple
<br />Creek Colorado
<br />;TINGASSl1CN 210. NAME AND ADDRESS OF FACILITY:
<br />ZIP:
<br />220. DATE FILED (Month, Day, Yeah _
<br />lL� /L/iy�
<br />PART OTHER SIGNIFICANTCONDITIONS- Conditions conlabuting to death but not related locausein 35. AUTOPSY 36. IF YES were findings considered
<br />II PART 1 (e g- al-001 abuse, obesity. smoker) (Yes or No) in determining cause of death)
<br />No
<br />6/26/00 Per Mine Safety & Health Administration letters claiming mining official located
<br />the body at the bottom of Mary McKinney mine, an abandoned mine shaft. Body not
<br />recovered, shaft partially filed with dirt and capped with concrete, dated 5/23/86
<br />and 10/10/86.ts
<br />enac.lR 1.RQfR -v 1.011
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD WHICH IS IN MY CUSTODY.
<br />1q�1 I DATE ISSUED JUN 2 6 2000
<br />( _ Jul CAROL J. GARRETT, PH.D.
<br />STATE REGISTRAR
<br />Do not accept unless prepared on security paper with engraved border displaying the Colorado state;
<br />seal and signature of the Registrar. PENALTY BY LAW, Section 25 -2 -113. Colorado Revised
<br />Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use
<br />env vital onlittirc rrrnrd NnT VAI Ill iF PT40Tn(- 0PIFTl _. _.
<br />Deputy State
<br />June 26, 2000
<br />23. TIME OF DEATH
<br />st seen
<br />2 <. DATE PRO OU CED DEAD
<br />Month Day YNI HON
<br />25. WAS CORONER NOTIFIED7
<br />2.45 PM
<br />m
<br />(Y. -NO)
<br />Yes
<br />TO BE COMPLETED ONLY SY CERTIFYING PHYSICIAN
<br />TO BE COMPLETED BY CORONER
<br />26. Tolhebestoimyknowledge, dealhoccurredatth efime,dateandpl- ..,4d..I.
<br />the uuaNs) aM ma eras satad.
<br />Sfgnalura►
<br />27. On the basis of examination and/or invests nmyopiMOrl deals occurtedeltne
<br />lime. date and , an0 due to the a Is) `d�'annsr n stated
<br />Signarore� �l �` `Yy, /,-
<br />j�-{ (�
<br />T
<br />28. DATE SIGNED IMonlh. Da,; Yost)
<br />29. DATE SIGNED (kfonlh. Day. Year)
<br />2
<br />-m ?5,
<br />30. NAME, TITLE AND MAILING ADDRESS OF CERTIFIERICORONER (Type/Pnn,,
<br />3
<br />Deborah R. Smith, M.T.(ASCP), Ph.D. 11 � ngeros�,WM
<br />zip: 80863
<br />31. NAME Of ATTENDING PHY$ICMN IF OTHER THAN CERTIFIER (Type/Pnnf) ,
<br />4
<br />32. MANNER OF DEATH
<br />33. DATE OF INJURY 330. TIME OF 33c. INJURY AT
<br />33d DESCRIBE HOW INJURY OCCURRED
<br />S-
<br />❑ Natural ❑Pending
<br />(Month Da,:Y..r) INJURY WORK?
<br />About
<br />Deceased fell to his death down an
<br />InYastigation
<br />M ❑Yet Jig NO
<br />27,1986
<br />0A«ident
<br />pr.
<br />dosed mine shaft
<br />O
<br />her
<br />-
<br />33e. PLACE OF INJURY -N home, lam) aasaL factory, office
<br />331. LOCATION (Streel and Number w Rural Rohe Number, City, County. State)
<br />❑ Homicide
<br />bwwkw..tt.(Sp..1Iy, Mine Shaft
<br />mi. S of Cripple Creek, Teller;=00
<br />PART 3+. IMMEDIATE CAUSE [ENTER ONL YON£ CAUSE PER LINE FOR (aL (01 AND (CLI Do not enter mode of dying (a.0. Cardlsc or Respiratory Arrast)okmo.
<br />Inter -al between onset
<br />,nd d :a1n
<br />•
<br />t u) fIntlPferminf-A
<br />Unknown
<br />a
<br />CONDITIONS DUE TO OR AS A CONSEQUENCE OF
<br />IF ANY WHICH
<br />IMOMI botween onsal
<br />GAVE RISE TO (b)
<br />and death
<br />IMMEDIATECAUSE
<br />STATING THE DUE TO OR AS A CONSEQUENCE O
<br />I.I. -I between ortsel
<br />UNDERLYING CAUSE
<br />and deal.
<br />LAST (c) Icl
<br />PART OTHER SIGNIFICANTCONDITIONS- Conditions conlabuting to death but not related locausein 35. AUTOPSY 36. IF YES were findings considered
<br />II PART 1 (e g- al-001 abuse, obesity. smoker) (Yes or No) in determining cause of death)
<br />No
<br />6/26/00 Per Mine Safety & Health Administration letters claiming mining official located
<br />the body at the bottom of Mary McKinney mine, an abandoned mine shaft. Body not
<br />recovered, shaft partially filed with dirt and capped with concrete, dated 5/23/86
<br />and 10/10/86.ts
<br />enac.lR 1.RQfR -v 1.011
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD WHICH IS IN MY CUSTODY.
<br />1q�1 I DATE ISSUED JUN 2 6 2000
<br />( _ Jul CAROL J. GARRETT, PH.D.
<br />STATE REGISTRAR
<br />Do not accept unless prepared on security paper with engraved border displaying the Colorado state;
<br />seal and signature of the Registrar. PENALTY BY LAW, Section 25 -2 -113. Colorado Revised
<br />Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use
<br />env vital onlittirc rrrnrd NnT VAI Ill iF PT40Tn(- 0PIFTl _. _.
<br />
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