|
(STATE OF COLORADO) ' /
<br /> \\---- i - ` <CERTIFICATION OF VITAL RECORD- ` -
<br /> \ x "t .1 .• �^___ ,___'.. _^ 7_^ v' vm.v s w .W yr :�Yn "...-4 ~.I
<br />.1.:,:-,, °,a`r �I'�l lilts+ ' CERTIFICATE OF DEATH STATE FILE NUMBER 1052019016140 �,, �,
<br /> :iv vv DECEDENT'S LEGAL NAME DATE OF DEATH 'gal J'
<br /> a( ,_ NICK HUNTINGTON GRAY MAY 24,2019
<br /> SEX SOCIAL SECURITY NUMBER AGE-Last Birthday(Years) UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH(Mo/Day/Yr) BIRTHPLACE(State or Foreign Country) �_
<br /> -7/
<br /> Months Hours Minutes
<br /> „�' MALE 524-28-4557 100 Days FEBRUARY 11,1919 COLORADO ) .
<br /> IF DEATH OCCURRED IN HOSPITAL IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
<br /> DECEDENTS HOME
<br /> Facility Name(If not institution,give street&number) CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH
<br /> 1 {, 584 6530 ROAD MONTROSE MONTROSE
<br /> JRESIDENCE-STREET AND NUMBER APT.NO. ZIP CODE INSIDE CITY LIMITS :'_
<br /> „: 584 6530 ROAD 81401 YES
<br /> RESIDENCE STATE C, i 1:::.:: OUNTY CITY OR TOWN
<br /> COLORADO MONTROSE MONTROSE
<br /> DECEDENT'S USUAL OCCUPATION(Give kind of work done during most of working life.Do not use retired) KIND OF BUSINESS/INDUSTRY DECEDENT'S EDUCATION
<br /> CATTLEMAN RANCHING 19TH-12TH GRADE,BUT NO DIPLOMA
<br /> ? DECEDENT OF HISPANIC ORIGIN DECEDENTS RACE ;}
<br /> NO White
<br /> °�.
<br /> EVER IN US ARMED FORCES MARITAL STATUS AT TIME OF DEATH SPOUSE/PARTNER NAME(If wife give name prior to first marriage)
<br /> ' YES DIVORCED
<br /> FATHER'S NAME MOTHER'S NAME PRIOR TO FIRST MARRIAGE
<br /> (�w
<br /> v If JOSEPH O'DRISCOLL GRAY ADELINE HOBSON
<br /> INFORMANTS NAME INFORMANT'S RELATIONSHIP TO DECEASED
<br /> s 3 LEZLEE COX GRANDDAUGHTER -x”
<br /> i NAME OF FUNERAL HOME CITY AND STATE OF FUNERAL HOME WAS CORONER NOTIFIED -
<br /> CRIPPIN FUNERAL HOME,INC. MONTROSE COLORADO YES
<br /> METHOD OF DISPOSITION PLACE OF DISPOSITION LOCATION-CITY,COUNTY,STATE v`.
<br />'''N'I i, CREMATION CRIPPIN CREMATORY MONTROSE MONTROSE COLORADO "I'"'o;
<br /> INJURY AT WORK IF TRANSPORTATION RELATED,SPECIFY DATE OF INJURY TIME OF INJURY
<br /> NO MAY 19,2019 UNKNOWN
<br /> PLACE OF INJURY
<br /> g'
<br /> UNSPECIFIED PLACE
<br /> LOCATION OF INJURY
<br /> 0:
<br /> c DESCRIBE HOW INJURY OCCURRED ki
<br /> \\ FALL FROM HORSE ON DECEDENTS RANCH PROPERTY RESULTING IN MULTIPLE TRAUMATIC INJURIES
<br /> ' WAS DECEDENT UNDER HOSPICE CARE ACTUAL OR PRESUMED TIME OF DEATH DATE PRONOUNCED DEAD(MO/DAY/YR) TIME PRONOUNCED DEAD
<br /> YES APPROX 06 50 MIL MAY 24,2019 07:05 MIL :
<br /> MANNER OF DEATH WAS AN AUTOPSY PERFORMED WERE AUTOPSY FINDINGS CONSIDERED IN DETERMINING
<br /> ACCIDENT NO THE CAUSE OF DEATH?
<br /> ti CAUSE OF DEATH f7
<br /> PART i Enter the chain of events-diseases,injuries,or complications-that directly caused the death. Approximate interval:
<br /> IMMEDIATE CAUSE(Final disease or a MULTIPLE TRAUMATIC INJURIES Onset to death
<br /> condition resulting in death) _ ..__. _____--..__ __—_-__ _:___ 5 DAYS ' ' /-.
<br /> b FALL FROM HORSE 5 DAYS -'
<br /> Sequentially list conditions,if any, ,s.i,
<br /> leading to the cause listed on line a c
<br /> Enter the UNDERLYING CAUSE
<br /> (disease or injury that initiated the
<br /> events resulting In death) d 611
<br /> e,{
<br /> t.
<br /> PART II Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
<br /> DECEDENT RECEIVING HOSPICE SERVICES FOR CORONARY ARTERY DISEASE PRIOR TO HIS FALL. _
<br /> TITLE,NAME,ADDRESS,ZIP CODE AND COUNTY OF PHYSICIAN DATE SIGNED �-
<br /> SHANNON K KEEL MD 2754 COMPASS DRIVE STE 377 GRAND JUNCTION CO 81506 MAY 24,2019 )1 f
<br /> ,::‘,.:)1•
<br /> TITLE,NAME,ADDRESS,ZIP CODE AND COUNTY OF CORONER DATE SIGNED f�
<br /> THOMAS M CANFIELD MD COUNTY CORONER 1200 N GRAND AVENUE BIN F MONTROSE COLORADO 81401 MONTROSE MAY 28,2019 {)
<br /> DATE FILED BY REGISTRAR
<br /> MAY 29,2019
<br /> /
<br /> x MAY 29,2019 /
<br /> �� it"\\"»iautttq I DATE ISSUED / ��....,�___N-�ftt\ li t'
<br /> "OF•Col�`-•-'.''ry THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS OF•'COl
<br /> .,O /i A.ALEX QUINTANA
<br /> ��i� RECORDED IN THIS OFFICE Do not accept unless prepared on STATE REGISTRAR
<br /> / Qt j sa-�_.-„-,- X'....€1 •// security paper with high resolution border displaying the Colorado state Q, sZ_0:
<br /> o?h. - ` \ ° seal and signature of the Registrar-PENALTY BY LAW,Section 25-Zp-118, II II II II III I IIIIII III II ":*1
<br /> ',in' .0
<br /> !�' II Colorado Revised Statutes, 1982,if a person alters,uses,attempts to
<br /> '* ` i fit,/' use or furnishes to another for deceptive use any vital statistics record. * * , * ` �`
<br /> NOT VALID IF PHOTOCOPIED
<br /> ``` * REV 04116 009179969 *- */
<br /> c
<br /> ` .. AU
<br /> yyyyyyyyyyyy�"C�XY
<br /> 6 c" E E VOIDS THIS CERTI ``Y=-�x illi ,,".',T-', '
<br /> (' �titttgn�tm��o�"�• -�.,,y-_ ,' „ANY •L E•� I• •• t `-� �= / � Ill itlt�gm���o����"�"'� '``.
<br />
|