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CERTIFICATE OF DEATH STATE FILE NUMBER.,. 1052019001922 ' DECEDENTS LEGAL NAME - DATE OF DEATH ALVIN JOE MOSCH JANUARY14.2019 SEX SOCIAL SECURITY NUMBER JAGE-Last Birthday(Years) UNDER 1 YEAR LADER 1 DAY DATE OF BIRTH(MOIDayIYr) BIRTHPLACE(State or Foreign Country) MALE 521-34-6172 8B Months J Days I Hours Minutes JUNE 10,1930 COLORADO IF DEATH OCCURRED IN HOSPITAL iF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL DECEDENTS HOME i !! i Facility Name(If not institution,give street a number) CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH 1520 WALL STREET IDAHO SPRINGS' CLEAR CREEK e RESIDENCE-STREET AND NUMBER - APT.NO. ZIP CODE INSIDE CITY OMITS - 1520 WALL STREET 80452 YES .a RESIDENCE STATE COUNTY - CITY OR TOWN COLORADO CLEAR CREEK IDAHO SPRINGS { DECEDENTS USUAL OCCUPATION(Give kind of work done during most of working fife.Do not use retired) KIND OF BUSINESS!(NDUSTRY DECEDENTS EDUCATION PROSPECTOR MINING ASSOCIATE DEGREE A J DECEDENT OF HISPANIC ORIGIN DECEDENTS RACE •'+�--'-�v NO VN1ile Mir ��+W EVER IN US ARMED FORCES MARITAL STATUS AT TIME OF DEATH SPOUSE/PARTNER NAME(If wife give name prior to first marriage) YES WIDOWED PATRICIA COLLENE HAROLD A to FATHER'S NAME - - MOTHERS NAME PRIOR TO FIRST MARRIAGE r1 400 HANS MOSCH ELIZABETH LAHNERT es'-" { INFORMANTS NAME - INFORMANTS RELATIONSHIP TO DECEASED W DAVID MOSCH '.SON •• NAME OF FUNERAL HOME - CITY AND STATE OF FUNERAL HOME WAS CORONER NOTIFIED r KIBBEY FISHBURN FUNERAL HOME LOVELAND COLORADO YES METHOD OF DISPOSITION PLACE OF DISPOSITION _OCATION-CITY,COUNTY,STATE =�QIA BURIAL-CEMETERY LAKESIDE CEMETERY-LOVELAND LOVELAND LARIMER COLORADO � lD INJURYATWORK IF TRANSPORTATION RELATED,SPECIFY 01 GATE OF-INJURY TIME OF INJURY �7i Nj V PLACE OF INJURY a LOCATION OF INJURY(Street 8 Number,ApL No.,City or Town,County,State,ZJpcode) - .A- y�i A +. DESCRIBE HOW INJURY OCCURRED -t nS WAS DECEDENT UNDER HOSPICE CARE ACTUAL OR PRESUMED TIME OF DEATH DATE PRONOUNCED DEAD(MOIDAYNR) TIME PRONOUNCED DEAD YES 05:53 AM JANUARY 14,2019 05:55 AM MANNER OF DEATH - WAS AN AUTOPSY PERFORMED WERE AUTOPSY FINDINGS CONSIDERED IN DETERMINING NO THE CAUSE OF DEATH? NATURAL CAUSE OF DEATH PART I Enter"cRain of events-diseases,injuries,or complications-that directly caused the death. Approximate interval: IMMEDIATE CAUSE(Final disease Dr a CONGESTIVE HEART FAILURE Onset to death condition resulting in death) 8 YEARS b SequenUatty list conditions,if any, leading to the cause listed an line a. C - Enter the UNDERLYING CAUSE (disease or Injury oat initiated the events resulting in death) d PART II Enter other siorYftoant conditions contdbutina to death but not resulting in the underlying cause given in PART I - CHRONIC A-FIB - TITLE,NAME,ADDRESS,ZIP CODE AND COUNTY OF PHYSICIAN - DATE SIGNED - TODD WISSER MO 30940 STAGE COACH BOULEVARD EVERGREEN CO 80439 JANUARY 18 2019 •� TITLE,NAME,ADDRESS.ZIP CODE AND COUNTY OF CORONER -; - DATE SIGNED fir) HARRIET S tLTON CHIEF DEPUTY CORONER PO BOX 2037IDAHO SPRINGS COLORADO 80452 CLEAR CREEK JANUARY 22 2019 CATE FILED BY REGISTRAR JANUARY 22,2019 :��•� """'tualll DATE ISSUED JANUARY 24,2019 ) `,.........,t�ttt C +tt4 r/l C OF' Ol p�r, THIS IS A TRUE CERTIFICATION OF NAIv1E AND FACTS AS ```1`OF' Ol A.ALEX QUINTANA O RECORDED IN THIS OFFICE:.Do not accept unless prepared on STATE REGISTRAR security paper with high resolution border displaying the Colorado state o seal and signature ofthe Registrar.PENALTYBY LAW,Section 25-2-118, I IIIIIII{llllllll IIII 11111111II II l III * ' Colorado Revised Statutes, 1982,if a person alters,uses,attempts to use or furnishes to another,for deceptive use any vital statistics record. NOT VALID IF PHOTOCOPIED. 009133463 �REV 04116 6 iL t ````\` - - . . • •. -• • a tw.,- _: _ "—��,R7B7�