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`, _�• CERTIFICATE OF DEATH STATE FIL�NURaI$ER 1C152tl20048214l: t
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<br /> - T DECEDENT'S LEGAL
<br /> '• , -- DECEMBER 02 2020 -
<br /> • '``'��'••'� � I EVAN LUDVIG MELBY ,•,lv�
<br /> SOCAL SECURITY NUMBER AGE-Last Birthday!Yeas; UNDER 1 YEAR j UNDER 1 DAY j DATE OF BIRTH(Mo DayrYt) BIRTHPLACE(State or Fore,gn Courtiryt'•^ _ �H
<br /> :3ti-c Days ur "' t'^u'es MAY WISCONSIN
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<br /> ALE
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<br /> ✓+ F DEATHOCCURRED'N Hw _---------�_L'�JCCUA,REt05:?f�rtE.M1'HF.RF�i,-+cR'nL•.a•,.S�"� •'q�,ai .'r..
<br /> --
<br /> f{ 1 ---- E:EDENT,5HOME
<br /> Fac,hN Name(if not insat'Ation,give sveat B number, CITY TD.NN OR LOCATION O=D--AT- ; NTH I
<br /> 3Z•, 2 507E HWY+Sc 1 SAN LUIS i COST1,LA jty
<br /> Y
<br /> R c-STREET AND NJt"BER APT tin Z'a"G:,E ;NFADE GTY LiMiTS
<br /> ES,DEN -
<br /> i 307E HW` i.c : YES
<br /> IENCE
<br /> COLORADO '_.CS"_'A SA -"S
<br /> y., D ECED ECE DEt 'S,�S..AL CC_LU-ATI;)°a C•re k.na of avY'd-^e_ c _C- se reKe,',-�KNND OF FUSINESS,INDUSTR•
<br /> cs�, LAND DEbELOPER SELF EMPLOYED
<br /> DECEDEN'CF^z=ary _ n DECEDENTS RACE
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<br /> RATHEP o-._� _.. .".:cc __ _� _-_ �_ - __3Ec._�-;cc•, ', H!'e".;e"a ,_, _ _ _._-_--._..-_-_.-..-______._
<br /> NO
<br /> t•;,.Hcc'S'4A°.1E FRI,�F TO FiRS
<br /> 'V
<br /> MORRIS A MELBY 1 PETRA LOUSTAD ^ "
<br /> `y�2�.s 'yF QRgtAT^"S N,>"sE iNFORMANT'S RFIATLONSHIP TC 3EOEF:E^ ^
<br /> L4RLENE MELBY CHILD
<br /> '- L•te OF'.NepcL- "E i C,Ta ANC:STA-E Oc;-- ;.EPAL-•.,',1t __' -_•E ED ��,,.�.
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<br /> ' ANGELUS FUNERAL DIRECTORS ING ! COLORADO SPRINGS CCLORAZCtz
<br /> ES Q
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<br /> ',,ETHOD OF DSPOS-iON -L.+CE OF DIS-OSiTICTs _� `•^4 °=-`�c ,° �
<br /> }� CREMATION ANGELUS CHAPEL CREMATORIUM :,�:' :. S%'R•^JGS EL PASO COLORADO
<br /> St X
<br /> „ _--i DECEMBER���'.— '-ES'liMED C``C'PM
<br /> ,F'PAN°POR'A'IC%RE_A'ED SPECIFY DATE OF'NJU4Y /�F"JURY
<br /> --/I HOVE CECEDENT'S RESIDENCE
<br /> '�$• �-a V---U., C..e:t d Nv ntae ',Oi NG,C,ty:,Tow;- _ ., -- . _...' i r�L
<br /> 'iW%Y"=c SAN LUIS COSTtLLA COLORADO 81152 t
<br /> DESCRIBE-C: 'N1URv OCOJRREC 11," 1
<br /> ,,v+ CEI.tDENT..AS FG;_NU'DF':EASEC AND FROZEN OUTSIDE H:S G cS•_. _ �,q
<br /> tii J co..rSc�E = ,i4:OR FPEo.. _ -�RtE, I•" ,
<br /> - PRESUMED C5`_
<br /> ACCIDENT
<br /> rr• CAUSE OF DEATH
<br /> me c;a•e:•e�r-3- - _ - - - -. -ase.•4e dear: ___-'e-•a. �
<br /> R HYPOTHERML
<br /> b-_HYPERTENS,tktJ;, E'U - _--ASZiLARDISEAS- _— ----- YEARS - it
<br /> Seq,entw::y'sl Cor7,Lons Zany. '-`------ ,
<br /> I reading to tine cause listed on Nme a C AGE-RELATEC NEL'FG'=BR-;_.AR ;ENE'P-'CN UNKNOWN
<br /> Enter the UNDERLYING CAUSE
<br /> y •an.a<_e or rnlury that-b-mee me
<br /> _,r.-,•.e, c,g"Fran;-cr;:,c^�s cC,;nrunnD r'7ea'- ,,, cc•ear
<br /> CHDLEUTHASIS MILD DECOMPOSITION _
<br /> ai ------`- LORE;5 �GDE 4fvC�'DJ•JT _Py+S,:.y+- --. __._-__ _ _`,E_
<br /> +6 TITLE NLVF A.D RESS,ZIP CODE AND COUNTY Ce CORONER CATE S'GNED }�
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<br /> '•Wj .. t,- S' - 5L-c- 2 --_ _'AtiUARY:` --` is
<br /> y' SHERRi btulL�EPJTI t,ORONER _A1A'N -ZE='a"h COST'LLA __— ------ ----._--
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<br /> F
<br /> DEL,..,"RFR
<br /> AMENDED
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<br /> JANUARY 26,242140
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