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DECEDENT
<br />2
<br />CAUSE OF
<br />DEATH
<br />TIT
<br />143E TIFIeflef - zeoRDI„.
<br />.
<br />,
<br />AlM1M ;;
<br />STATE OF COLORADO
<br />COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
<br />HOLD TO LIGHT TO VIEW WATECRIVIARK
<br />STATE OF COLORADO
<br />CERTIFICATE OF DEATH
<br />Book 44, No. 56, Dist. 102
<br />1. DECEDENTS NAME (Firs{ 1114450 1.8011
<br />Marion Adam RUDIBAUGH
<br />4. p
<br />
<br />WAS DECEDENT EVER tN
<br />U.S. ARMED FORCES?
<br />HOSPRAL:
<br />CVOS 0 No 0 Inpatient ER/Outpatient 0 00A
<br />90 . FACILITY NAME5I nof10sSIW1ion . give street and numb.)
<br />5291 Cougtr:Rd 76
<br />DECEDENTS USUAL OCCUPATION
<br />,Mira kind oriyod rdone Offing most of working tile
<br />pri not doe retired)
<br />Rancher
<br />13M- RESIDENCEiSTATE 13b. COUNTY
<br />I
<br />COloradd: ,'' Gunnison
<br />13s. INSIDE 131. ZIP CODE
<br />CITY
<br />LIMITS?
<br />No
<br />° 81239
<br />17; FATHER-NAME VOA 11(4010. 1.851)
<br />Adam Pancake Rudibaugh
<br />20a. METHOD OFDISPOSITION:
<br />0 BON CreedStiorEl RennivaNrom State
<br />a Oonattai) o*er0iis14u4 -
<br />336.
<br />2). SIG OF FU$ERA).pI RECT9KOftPER$OMACTINGASSUCH
<br />23.TIM�C000ATH r ,,c ir e ANONOUNCED DIA?
<br />0845 m lNovember 16 .
<br />TO BE COMPLETED ONLY BY CERTIFYiNG PHYSICIAN
<br />26. To Me best of nay knowiedge.death occumsd at the Erne. date and Mace. and due to
<br />Me came(s) and Manner es staled.
<br />28, DATE SIGNED (Month. Dayl Year)
<br />5a. AGE Last
<br />Birthday (Yea 4
<br />85
<br />5b. UNDER 1 YEAR
<br />os
<br />9a. PLACE OF DEATH (Check only one)
<br />kkcput.lup
<br />30. NAME. TITLE AND MAILING ADDRESS OF CERTIFIER/CORONER (Type/FT/M)
<br />Frank Vader, , Coroner PO .303, Gunnison,
<br />' 31: NAMEOF ATTEND, G PHYSICIAN I .0TH -THAN CERTIFIER IType/Pnn0
<br />>
<br />. 32. MANNER OF DEATH .. . .... 33a. DATE OF INJURY.. 33,: 330. INJURY AT
<br />(AtiTt/i/Das i
<br />. 03 4 Mii*
<br />' ' ,... ., „ •.,,-, Inyeaniamtim ::-: ..:',: M : "e' 6 N °
<br />' . bAcci;jent . ..i., .... ,. ..
<br />. .. . .
<br />.. .... .. :::::,.....,.
<br />0 Undetermined
<br />0 Suicide Manner 33e. PLACE OF INJURY141 bortM, Nan. West. tectOfy.019oe
<br />buIldIng.etc.(Spacde
<br />30. immimiATE CeAlSE WITENONLY 04t CALlig PENilta FOR AND (AU* lie, en* znocleof dOilg (e*Certettc
<br />• Complications ' from Pancreatic Cancer
<br />CONDITIONS DUE TO OR AS A CONSEOUENCE OF
<br />IF AMY WHICH
<br />dmMEDIATE CAUSE
<br />STATING THE DLIBTO OR AS &CONSEQUENCE:0F
<br />uNrigairkoc4ai
<br />Ranching
<br />5c. UNDER 1 DAY
<br />Hrs : Mins
<br />.10b. KIND OF BUSINESS/INDUSTRY
<br />120. CITY. TOWN. OR LOCATION
<br />Perlin
<br />14. WASOECEDENT OF HISPANIC ORIGIN?
<br />13 0°D 'T RI 70 . - Yes. openly Cuban,
<br />exican. Puerto Rican. etc.) .
<br />3 No Yes
<br />Speedy: '
<br />9. MOTHER Font 111441.1.1.6 t I(tuden Name))
<br />Mary Morris
<br />S. DATE OF BIRTH
<br />WM.!" 0 .A v
<br />: June 26.; 1924
<br />• OTHER
<br />I 0 Nursing Home X Residence 0 Other ISPect4)
<br />90, CITY. TOWN, OR LOCATION OF DEATH
<br />20b. PLACE OF DISPOSITION (Name of cemetery. crema(ory.01
<br />other plate).
<br />Crippin Crematory
<br />PART OTHER SiGNIFICANTCONDITIONS -ConMtions contributing to death but not rotated to cause
<br />11 PART I o alcohol abuse. obesity. smoked.
<br />. „
<br />STATE FfilE,NUMilER
<br />a DATEOF DEATH (Month:Day. Teen • November 16, 2009
<br />7. BIRTHPLACE (Ci)y and State or Foreign
<br />Country)
<br />Lisbon; Ohio
<br />84. COUNTY OF DEATH
<br />Perlin Gunnison
<br />19. MARITAL STATUS:- Married. 12: SPOUSES/ ISA glye molder mune)
<br />Deborah Sue
<br />Married Trautman
<br />13d. STNEET NUMBER
<br />5291Cniinty Rd, 76
<br />15. mos: Amerman Indian, 16. DECEDENTS EDUCATION (Space y only bighest
<br />Wack hfte. 11111 e" frl i rC14 6 1 :PAZ: 4:76 ? 7 4 1
<br />White
<br />FIa, 800,
<br />2009.. .1135
<br />9. 1NFORMANTNAME end reltitiOESIEP1p *teemed ..
<br />Deborah Rudibaugh-Wife
<br />20c. LOCATION • City or Town. State
<br />Montrose, Colorado "
<br />210 NAME AND ADDRESS OF FACILITY:
<br />Crippin Funeral Home, :Inc.
<br />802 E. Main St . , Montrose, Co 81401
<br />220. DATE FILED (Montn. 0091.00819
<br />atw..../a g 2_009
<br />25 MS riarran
<br />Yes
<br />TO RE COMPLETED BY CfNIONETI
<br />27. On tbe basis otexambtation amMor InvestIgedon. In myopinion death oocumNi et the
<br />time. date and place, *04 due tattle cause($) and manner as stated.
<br />Sionarune 61
<br />29. DATE SIGNE� (M�olh, 080. .10)9
<br />,V4&4' r, a--(567
<br />Col oraci' •
<br />Dg.senteE Ntwoccurorcp
<br />331. LOCATION gatsetand Nue/two, Rural Route Number. City, County. S(ate)
<br />Intelyal between
<br />end
<br />.•-•• 1 'Veer
<br />.-•. DATEISSUED ' 6 114.. ...o 0 9,i. ..- , - ::::.
<br />,.... - 11 : r - _. . ': :. ..:,___- E _ : .,.. ..., .; -FONALD S. HYMAN
<br />,i6 TH I
<br />IS S A TRUE CERTIFICATION OF NA AND FACTS AS STATE REGISTRAR
<br />RECORDED IN THIS OFFICE. Do not accept unless prepared on
<br />and . , , :':: II ll III I 111 111
<br />1 security paper with engraved bordendisplaying the Colorado state seal, .
<br />signature of the RegiStrar PENALTY BY LAW Section 25-24118
<br />_ g Colorado Revised Statutes, 1982, if a person alters, uses attempts to s '"•-
<br />■ ...;
<br />..1 use or furnishes to another for deceptive use any vital statistics record.
<br />0 0 3 0 9 3 7 0 5
<br />Interval between onset
<br />and death
<br />Interval between onset
<br />and death : •.•
<br />;.,
<br />35. AUTOPSY 36. IF YES were findings oonsIdered
<br />lYos or No) in determining cause 14 4.8(0?
<br />, RIBcp1Me,
<br />' I 3 7fyi..
<br />. A
<br />ENVStOrV0 "
<br />--- Miring Of -§ateiii
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