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<br />1. DECEDENT'S NAME (First. Middle. Last) 2 SEX 3 -PATE OF DEATH (Month, Day. Year)
<br />Erinis Do le BIJUABAY Male Ja a 9010
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<br />
<br />
<br />
<br /> OTHER
<br />HOSPITAL
<br />6F .
<br />? Inpatient O ER/Outpatient ? DOA ' ? Nursing Home `K Rasltlehe O Other (Specify)
<br />9b. FACILITY NAME',Uf not institution, give street and number) 9c. CITY, TOWN, OR LOCATION OF DEATH 9d. COUNTY OF DEATH
<br />
<br />
<br />.
<br />2 Ride Rd.
<br />22
<br />A Louisvi le
<br />
<br />Boulder
<br />CCUPATION
<br />Toe. DECEDENT'S IJAM 1D KINDOFBUSINESSfINDUSTRY 11. MRR AL: TATUS Married,
<br />Na Married Widowed 12 SPOUSE III wits give maiden name)
<br />(tGive kindol work donedunnginosfolwo knyllle.
<br />b
<br />/ ,
<br />Olvorced
<br />(Specify).
<br />o not use retired),..
<br />`
<br />Geologist Oil Widowed nzel A. McDonald
<br />13a RESIDENCE-STATE 13b. COUNTY c CIN. -'-N -- TION Jd. Tr ET-A'+u t UM3 R;: '
<br />'Colorado Boulder Louisville 222 Ride Rd:..
<br />13e. INSIDE 13f. TIP CODE 14. wASDECEDENT OF HISPANIC ORIGINS 15 RAGE Amercan lndlan,. 16. DECEDENT'S' EDUCATION (Specify onlybighest
<br />CITY
<br />LIMITS? (Spacily No or Yes Il let, pacify Cuban:
<br />Ma Ic n, Puerto Rcan Ic IS
<br />a 1
<br />Black, Whits etc. (Spec lyl yyrede eompie[ed)Ela mentary or secondary
<br />(O through 12) College (13 through 16 or 17+)
<br />?YB OVes
<br />No
<br />?NC :.. 80027 sPncry white 17+::
<br />17 FATHER NAME (F/taf, Middle Last) it, MOTHER - (F-1 Middle Last (Maiden Name)) 19 INFORMANT-NAME and mlatiOnship to decease
<br />Personal
<br />Ennis Do I e Huckaba _Sr. Margaret Honaker JoAnn Greaves-Re rese tative
<br />20a. METHOD OF DISPOSITION 20b. PLACE OF DISPOSIT ON (Name of cemetery, crematory, or loc. LOCATION - City or Town, State
<br />[XBurial..?Crematon: ??Removal from State olh er place) -
<br />oDP atio bather(Specify) Louisville Cemetery Louisville, :;Colorado
<br />21. SIGNATURE OF FUNERAL DIRECTOR. OR PERSON. ACTING AS SUCH 21b. NAME AND ADDRESS OF FACILITY:
<br /> Darrell Howe Mortuary
<br /> 1701 W. South Boulder. Road
<br />`
<br />- ?` Lafayette, Colorado zIP. 80026
<br /> 22 EgISTBAR'S SI A R
<br />TE FILED (Month, Day. Year)
<br />22p
<br /> _
<br />a ?0.?1 t 5 °? d
<br />2. TIME OF DEATH 24.-DATE PRONOUNCED DEAD 25 WAS CORONER NOTIFIED?
<br />
<br />1955 M Month Dey Year Hour
<br />January 13 2010 1955 (Yes or NO)
<br />Yes
<br />TO B E COMPLETEMONLY BY. CERTIFYI NG PHYSICIAN TO. BE COMPLETED.BY CORONER ...
<br />
<br />
<br />curred at the ame, date and place and due to
<br />26. To the best of my knewle deaOc
<br />t'
<br />
<br />27. On the basis of eraminabon and/or 'nvestigatlon,in my opinion death oceurced at tha
<br />the cause(s) end me stated timedate and place and due to the cause(s) and manner a@ stated.
<br />.. S/p lure', .; Znarure0.
<br />, Day, Year)
<br />28. DATE SIGNED (Month
<br />V 29. DATE SIGNED (Month, Day, year)
<br />),
<br />`
<br /> ®
<br />
<br /> 30. NAME, TITLE ANOMAILING ADDRESS OF CERTIFfER/CORONER (Typelgnnt) ?
<br />(
<br />3
<br />
<br />lEC . / G2?-?- ,'>?O' Y??s"A /,?yG !D Ey?/1???oz;P 15U3?3
<br />T',fi'/ G
<br /> 31. NAME OF'A7TENDING PHYSICIAN IF O HERTHAN'CERTIFY CERTIFIER (Typell"fint)
<br /> 4 32. MANNER OF DEATH:, 33a. DATEOF'INJGRY 33b. TIMEOF 33c. INJURY,AT.
<br />(Mont" Dag Year) INJURY WORKT d. DESCRIBE HOW INJURY OCCURRED -
<br />
<br />$. .
<br />
<br />1
<br />Natural ? Pending-
<br />Inyestigabon: bye D vas O No
<br />? Accident
<br />
<br />
<br />? O Suicide O Undetermined
<br />Manner 33e. PLACE OF INJURY-At home, farm, street, factory, office
<br />33f LOCATION (Street and Number or Rural Route Number, City, County, State)
<br />( - OHdmfcide pultding, etc. (Speclty) _ .,,, ..
<br />Y?r
<br />I 34. IMMEDIATE CAUSE (ENTER ONL Y ONE CAUSE.PER LINE FOR(.), (C), AND (c),i Do not enter mode of dying (e.g. Cardiac or Respiratorykrest)alone Interval between onset
<br />anddaegr
<br />/G ,.
<br />PART
<br /> • I
<br />la) ?(J /_11
<br />G T1
<br /> CONDITIONS DUE TOOK AS A CONSEQUENCE OF Interval between onset l
<br />and death
<br /> IF ANYWHICH
<br />_.
<br /> . GAVE RISE TO
<br />(b)
<br /> IMMEDIATE CAUSE DUE TO OR AS A CONSEOU -NCE OF .STATING T E Interval between onset
<br />and death
<br /> UNDERLYING CAUSE
<br /> LAST (c) Ic)
<br /> PART OTHER SIGNIFICANT CONDITIONS-Conditions contrbutng to death but not related to cause in 1 35, AUTOPSY 36. IF ZS were findings considered
<br /> 11 PART I (e.g alcohol abuse obesity, 'smoke ). :(Yea or No) i d t rminin0 cause . of dealh7 i
<br /> No
<br />
<br /> JUN I# '?fl ttJ / ..
<br />
<br /> DATE ISSUED ?t
<br /> RONALD S. HYMAN
<br /> THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS STATE REGISTRAR
<br />
<br />RECORDED IN THIS OFFICE. Do not accept unless prepared on I
<br />c ;
<br />Colorado state seal
<br />security paper with engraved border displaying
<br />the
<br />
<br />l
<br />I
<br />I
<br /> ,
<br />Section 25-2-118,
<br />and signature of the Registrar. PENALTY BYLA, I I
<br />I II III II III ?I?I III?I II I??? II
<br />l II ??IIL I
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<br />Illll
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<br />Colorado Revised Statutes, 1982, if a person alters, uses, attempts to° /
<br />1
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<br /> G? use or furnishes to another for deceptive use any vital statistics record. 0 0 41; 6 9 5 8 2 1
<br /> NOT VALID IF PHOTOCOPIED
<br />REV DiI
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