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<br />STATE OF COLORADO Rf
<br />COLORADO DEPARTMENT OF PUBLIC HEALTH.AND ENVIRONMENT
<br />WOLD,TQ LIGHT TO VIEW WATERMARK
<br />*AMENDED 62/24/2010 #4 per
<br />mortuary records;. is@'state
<br />STATE OF COLORADO
<br />
<br />
<br />spc@state c?
<br />tel. .. - - - "" 2. SEX 3., DATE OF DEATH(MOnth, Day. Year)
<br />1. DECEDENT'S NAME IFtret, Middle. Last)
<br />, e a
<br />" 6. DATE OF BIRTH 7. BIRTHPLACE (City antl State or Foreign
<br />Ennis Do le Ma J
<br />
<br />
<br /> 87
<br />8 WAS DECEDENT EVER IN 9a PLACE OF DEATH (Check my dnel
<br />ARMED:FORCESn HOSPITAL: ^ ^ OTHER
<br />- Home"XResidence ? Other (Specify)
<br />
<br />LyN es tea,.., ., ,,,I,.,.?,., ... _...__.._.._..
<br />TOWN, OR LOCATION OF DEATH
<br />9c. CITY
<br />3b. FACILITY NAME!(If not fnstitution, give street ,
<br />arM number)
<br />222\R1 d a Rd. Louisville .
<br />Monied. '. 12. SPOUSE (if wile, give maiden name)
<br />STATUS
<br />MAR aL:
<br />/ 1
<br />to.. DECEDENTS USUAL OCCUPATION .
<br />10b. KIND OF BUSINESSiINDUSTRY
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<br />(G ekndol work done duri ng Stofworki
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<br />--Widowed azel A. McDonald
<br />Geologist
<br />' 011
<br />oRtocar:uN s P C NUIJBER
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<br />se CITY
<br />-
<br />13a. RESIDENCE-STATE 'rT3b. COUNT ,
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<br />Colorado Boulder Louisville 222 Rid e Rd;.'
<br />ghest
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<br />73e. INSIDE 131. TIP CODE Ia O
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<br />-S DECEDENTOF H IVes, s, ORIGIN', ,5 . BRACE lack Amerca
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<br />No r Yes - II Yp through 12) College (13 through 16 or 17+)
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<br />Pu rtd Rcan, etc)
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<br />White 17+
<br />?NP 80027
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<br />t 8 MOTHEBNAM IF rs(,M dde tall (Harden Name]) 19 INFORMANT-NAME antl tale( pnshlp to decease
<br />t
<br />Personal
<br />)
<br />. FATHER-NAME (F,,Sf, Mitldle Lss
<br />17 Jo Ann Greaves-Re rese "ative
<br />naker
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<br />Ennis Do Le Huckaba o
<br />Sr. Mar are
<br />TPWn, State
<br />r rot 20c. LOCATION. If—.,
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<br />METHOD OF DISPOSITION
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<br />206. PLACE OF DISPOSITION (Name o
<br />.
<br />(Yeunai ?Cremation ? Removaltrom: State
<br />r
<br />- ..:.ether Place! __
<br />
<br />.Colorado -
<br />Louisville
<br />0:Donation ?OtheriSPeli
<br />r)-
<br />- ,
<br />Louisville. Cemetery
<br />21a. SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 21 b. NAME AND ADDRESS OF FACILITY: ,
<br />Darrell Howe Mortuary
<br /> 1701 W. South Boulder Road - zlP: 80026.
<br />Lafa ette Colorado(
<br />STRAR 'S SIS`aLJA R :
<br />22 EG 22y A?E FILED (Montt(, DeY. Veer)
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<br />25 WAS CNRnONER NOTIFIED?
<br />.
<br />.. .,..c c c a DATE PRONOUNCED DEAD
<br />Fir
<br /> Mentp 1955 Yes
<br />1955 M!January 13 2010
<br />R
<br /> TO BE COMPLETED. ONLY BY CERTIFYING PHYSICIAN T ,
<br />OBE COMPLETED.BY CORONE
<br /> tion. in
<br />ml.S 26. To the best of my knowle ,death occuned at the time, date and place. and due to 2 r tOimeh tlat es s Ol exam and due to/?ne oausels) and manner anion 9 s aced. occurred at the
<br /> and place
<br />stated
<br />
<br />
<br />m y
<br />the cause(s) antl ann a
<br />S 9nature
<br />h, _
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<br /> w^-f
<br />'Synature
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<br />29 DATE SIGNED (H
<br />Onfh, Day Year)
<br /> h, Day, Year)
<br />t
<br />28. DATE SIGNED (Mon
<br />
<br />z E,TFTLE AND MAILING ADDRESS OF CERTIFIER/CORONER (Type/!)riot) ::'
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<br />30. NA ..
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<br />/"?-(cK C . niG%?ffc jk1, y?/S??/??/G ;
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<br /> 31. NAME OF ATTENDIN PHYSICIAN (POTHER THAN'CERTIFIER (1,,1hml
<br />
<br />4 MANNER OF DEATH-
<br />32 -331 DATE OF INJURY 33b: TIME OYF
<br />INJUR 33c. %URK7 AT 33d. DESCRIBE HOW INJURY OCCURRED
<br />- . (Month, Day. Yes,)
<br /> ' _
<br />KNatural ? pending M O Yea ? No
<br /> •
<br />,
<br />cident ;'
<br />? A
<br /> c
<br />PLAOEOFINJURV At home, farm, street, factory. office 33I.LOCATION(Street and Number or RUrel Route Number, City, County. State)
<br />? Undetermined
<br />i
<br />id
<br />33
<br /> e.
<br />0 Su
<br />c
<br />e Manner
<br />building. etc. (Specily)....
<br /> ?Homicide
<br />Inteval between onset
<br />FOR(e),(D).ANO(U.)DO_Rot enter mode of dying (e.g Cerdlao or Respiratory Arrest)alone: anddepy+?u?/? •.
<br />IN
<br />E
<br />34. IMMEDIATE CAUSE IENTERQIJLYDNECAUSE.PER L
<br />.' A
<br />,,
<br />J
<br />PART
<br />
<br />tween onset
<br />al b bel
<br />I
<br />t
<br />a
<br />r I (a) ?
<br />CONDITIONS DUE TO OR AS A CONSEQUENCE OF erv
<br />n
<br />and death
<br /> \
<br />IF ANY WHICH .? - -'-
<br />?. GAVE RISE 70 Interval between onset
<br /> IMMEDIATECAUSE DUE 70 OR AS ACONSEORW OF and death
<br /> STATING THE
<br />-UNDERLYING CAUSE
<br /> LAST (c) (e)
<br />
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions cunt buting to death but not related to cause in .. :; sidered
<br />35. AUTOPSY 36. IF VES were hndiIngle-
<br />:..(ye, or NO) 1' determining cause of death? r
<br /> II PART I (e.g., alcohol abuse, obesity, 'amokert
<br /> No
<br />
<br /> JUN
<br />r Vj // p
<br />?-
<br />+? J\" ltlij
<br />` DATE ISSUED RONALD S. HYMA. N
<br />I THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS STATE REGISTRAR
<br />( RECORDED IN THIS OFFICE. Do not accept unless prepared on l
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<br />PENALTY BYLAW, Se c
<br />re I
<br />the Reg stray
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<br />f
<br /> emp
<br />Colorado Revised Statutes, 1982, if a person alters, uses,
<br />O n
<br />0 4 6 9 5 $ 2 1
<br />G use or furnishes to another for deceptive use any vital statistics record.
<br /> NOT VALID IF PHOTOCOPIED REV ono i
<br />
<br /> idiiii
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