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<br /> STATE OF COLORADO
<br /> CERTIFICATE OF DEATH STATE FILE NUMBER
<br /> 1.DECEDENTS NAME(First,Middle,Last) 2,SEX 3.DATE OF DEATH(Month,Day,Year)
<br /> George Fredrick GALLEGOS Male March 4,2018
<br /> >: 4.SOCIAL SECURITY NUMBER 5a.AGE- Sb.UNDER 1 YEAR Sc.UNDER 1 DAY 6.DATE OF BIRTH 7.BIRTHPLACE(City and State or Foreign Country) -
<br /> (Years) U Days re M:'ns Mdnth Day Yea,
<br /> 521-44 1751 84 February 15 1934 Antonito,Colorado
<br /> 8.WAS DECEDENT EVER 9a.PLACE OF DEATH(Check only one)
<br /> IN U.S.ARMED FORCES? HOSPITAL: i OTHER:❑ Assisted LivlaglNursing Home ❑ Hospice Decedent's Residence �e$�
<br /> ❑ Yes 2 No ❑ Inpatient ❑ ER/Outpatient ❑ ODA ! ❑ Other(Specify) �Le
<br /> b. A INAME(if not institution,give street and number) 9c.CITY, WN, R L CATIO OF DEA H 9 UN F DEATH
<br /> 12127 Highway 285 Romeo Conejos
<br /> 10a.DECEDENTS USUAL OCCUPATION(Give kind of work lob.KIN OFBUSINESS4NDUSTRY11.MARFIAL STATUS 12.SPOUSE/PARTNER(It female,give maiden name) (&
<br /> V done during most of working life.Do NOT use retired) ❑Married ❑Never Married t
<br /> widowed ❑Divorced
<br /> LU Rancher Ranching ❑Unknown ❑Civil Union Virginia Romero
<br /> t 3a.RESIDENCE-STATE 13b.COUNTY 13c.CITY,TOWN,OR LOCATION 13d.STREET AND NUMBER
<br /> Colorado Conejos Romeo 12127 Highway 285
<br /> Q 3e.INSIDE CITY LIMITS? 13f.ZIP CODE 14.WAS DECEDENT OF HISPANIC ORIGIN? 15.RACE:American Indian,Blade,White,etc. :(Specify�r11y Fghis gacle
<br /> W ❑ Ves No (I�es",specify Cuban,Mexican,Puerto Rican,etc.) (Specify) ccmplet Elementary or secondary(6.12)
<br /> Copege(13 16 or 17,)
<br /> 81148 N Yes Specify:Spanish White 12
<br /> 17.FATHER/PARENT ONE-NAME(Frst.M;ride,last it lemele.gve 18.MOTHER/PARENTTVVO-NAME(FtstMddle,Ust ilbmale.gim 119.INFORMANT-NAME and relationship tociewased
<br /> ma'den Dame) maiden reme)
<br /> LL Rudolph Gallegos Anna Lucero Gale Swafford-Daughter
<br /> Oa.METHOD OF DISPOSITION ❑Alkarne Hydrolysis 20b•PLACE OF DISPOSITION(Nana of cemetery,crematory,or other place) 20c.LOCATION-City or Town,State
<br /> w ❑BuriaVEntombment 0 Cremation ❑Removal from State
<br /> ❑Donation ❑Other(Spacif) Roger's Crematory Alamosa,Colorado
<br /> 21a.SIGNATURE 0,FUNERAL DIRECTOR OR PERSON,ACTING AS SUCH 21b.NAME AND ADDRESS OF FACILITY
<br /> S,gnamraaa'' .) / !. Romero Valley Funeral Home,Inc.
<br /> 1407 State Ave.Alamosa,CO.81101
<br /> •�,'., 22a.REG�STAA IQNAT / 22tz D_A7 FII..ED(Month,Day,Year) /
<br /> .` Signature
<br /> )WAS DECEDENT UNDER HOSPICE CARE? 3. E OF DEATH 24.DATE ND TIME PRONOUNCED DEAD 25.WAS CORONER NOTIFIED?
<br /> 8.25 Month Day Year Time
<br /> ;.
<br /> a Ves ❑No ❑AM MPM ❑wit March 4 2018 9:15 ❑ AM N PM ❑Mia Yea ❑No
<br /> TO BE COMPLETED BY SIGNING PHYSICIAN TO BE COMPLETED BY CORONER
<br /> '.26a.To the best of my knowledge,death oxurred at the time,slate and 27a On the basis of examination arxLor Invesugatan,in my opinion death occurred
<br /> t 'place,and due to the cause(s)and manner as stated ❑ MD at the time,date a lace, nd due the cause(s)
<br /> a manner as stated.
<br /> Signature` ❑DO Signature ❑ Coroner
<br /> V11W g AssotJDepury Coroner
<br /> W 26b.DATE SIGNED(Month,Day,veer) 27b.DATE SIGNE (Month,Day ear) -
<br /> Z March 5,2018
<br /> O 26c.NAME,AND MAILING ADDRESS OF SIGNING PHYSICIAN 27c.NAME AND COUNTY
<br /> V, Doug Bagwell-Conejos County
<br /> 28.NAME OF ATTENDING PHYSICIAN IF OTHER THAN SIGNING PHYSICIAN
<br /> Q 9.MANNER OF DEATH 130.DID TOBACCO USE CONTRIBUTE TO DEATH 31.IF FEMALE:
<br /> V a Natural ❑Accidenl ❑Swcide ❑Ves ❑No ❑Probably ❑Unknown ❑Not pregnant wthin last year ❑Not pregnanl,but pregnant 43 days to 1 /
<br /> N ❑Homicide ❑Pend-ng Investigation ❑Pregnant at rime of death year before death A
<br /> ❑Undeterminetl ❑Not pregnant,but pregnant within 42 days of death ❑Unknown If pregnant within the past year 9i
<br /> = 32a. (Month,Day, ear) b. OF I JURY 32c.INJURY AT WORK?3_2 R BE HOW iNjLjRTC5C-c-LTR-RTb-
<br /> CL ❑AM ❑PM ❑M:ft ❑ i
<br /> Yes ❑No -
<br /> 32e.PLACE OF INJURY.At home,farm,street,lactory,office budding,etc.(Specify)32f.LOCATION INJURED(Street and Number or Rural Route Number,City,Count',State)
<br /> i 33.IMMEDIATE CAUSE-enter only one cause per line for(a),(b),and(c).Do not enter mode of dyirg(e.g.Cardiac or Respiratory Arrest)alone. Interval between onset and death f
<br /> Part 1. a)
<br /> which gave rise End Stage Renal Failure Months
<br /> ditions ff any DUE TO OR AS A CONSEQUENCE OF: Intervalbetween onset antl sal I
<br /> which
<br /> to immediate
<br /> . cause stating the (b)
<br /> . underlying cause
<br /> (c). DUE TO OR AS A CONSEQUENCE OF: Interval between onset an death
<br /> last
<br /> c
<br /> Part 2.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not related to cause in Pan 1 34.AUTOPSY 5.I ,were nding9 cons) arse C�i.
<br /> �? I3n determining cause of deem?
<br /> ❑Yes �NO ❑ Yes ❑No
<br /> #474 ,
<br /> , I
<br /> 40
<br /> t - 6 2018 �
<br /> "\`.1 yuauqupuq DATE ISSUED MAR
<br /> F CD f'h E CEW171FICATl71`' OF NAME AND PAC:' AS
<br /> p 1p ,, I IiIS IS A TRUE A.ALEX Ot11NTANA
<br /> RECORDED lid THIS Ot riCE. De1 not ac apt unless t.cp red on STATE REGISTRAR ,� -; jai► -- '��
<br /> c Q 'y '; SeCltrlty gaper with hipl resnlulion bc;.der displa}nng the Cola tck,state �Q ,
<br /> 3 (� x;ll and signature of silo Rq;,ver.PEN A:T V BY LAW,Sectiat 2>-.'.•118,
<br /> I Iillll IIIII IIIN IIIII�I�IIIII IIIII IIIII IIIII II IIII I
<br /> Colorado R viutd Status:,:.. 1982,if a P won.-lten,u_ces aft iip
<br /> I
<br /> tt tk l u`;F:or filfnnh r.to another for deceptive uzL,in"vital Stati-ucs r:
<br /> *
<br /> :: .. U Q 8 5 7 4 3 1 1 / * i
<br /> 11,10TVALID It"PltOTOC•OPIED. NE * �" ' r!✓ '* SNE gu^"'�
<br />
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