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DEPARTMENT OF HEALTH, STATE OF COLORADO State File NO 60000 f .._...._..._..� <br />EDUCATION, AND WELFARE <br />u�lv xT to RVICE STANDARD CERTIFIOATE OF DEATH 8+ � <br />Re stzar i No. Dist <br />1. PLACE OF DEATH <br />2. USUAL RESIDENCE (Where deceased fined. JJ institution: Residence bet e <br />Il .. I. Std <br />�UDK �� � <br />DEPARTMENT OF HEALTH, STATE OF COLORADO State File NO 60000 f .._...._..._..� <br />EDUCATION, AND WELFARE <br />u�lv xT to RVICE STANDARD CERTIFIOATE OF DEATH 8+ � <br />Re stzar i No. Dist <br />1. PLACE OF DEATH <br />2. USUAL RESIDENCE (Where deceased fined. JJ institution: Residence bet e <br />e. COUNTY <br />Arapahoe <br />a. STATE b. COUNTY admission); <br />Colorado Ar h <br />b. CITY. TOWN, OR LOCATION <br />a LENGTH Or STAY IN I <br />C. CITY. TOWN, OR LOCATION <br />Englewood <br />1 Day <br />Englewood <br />d. NAME OF (If not in hospital, pine street addreaa) <br />d. STREET ADDRESS <br />HOSPITAL OR <br />Swedish Hospital <br />3025 S. Logan <br />_INSTITUTION <br />w IS PLACE OF DEATH INSIDE CITY LIMITS? <br />e. IS RESIDENCE INSIDE CITY LIMI Si <br />f. IS RESIDENCE ON A FARM <br />YES X NO O <br />I YES NO ❑ <br />1 YES ° N <br />3. NAME OF First Middle Last <br />d. DATE Month Day Year <br />e(TEyPr Or prii,� JOSEPH F. SELBY <br />OF <br />DEATH J <br />S. SEX <br />S. COLOR OR RACE <br />7. MARRIED XNWER MARRIED ❑. <br />S. DATE OF BIRTH <br />9. AGE (In years <br />IV UN ER i Y R 1 R <br />Months Days Hours Min. <br />Yale <br />White <br />WIDOWED❑ DIVORCW ❑ <br />V"") birthday) <br />1016 USUAL OCCUPATION (GiH kind of <br />10b. KIND OF BUSINESS OR INDUSTRY <br />It. BIRTHPLACE (State OT foreign country) <br />12. CITIZEN OF WHAT COUNTRY? <br />work signs during moM of working <br />7e Td <br />Ra it road <br />Kansas <br />U S <br />13. FATHER'S NAME <br />14. MOTHER'S MAIDEN NAM[ <br />" _ _ _ _ _ .— -- <br />- - - -- Eva Mae Jones <br />IS. <br />WAS DECEASED EVER IN U. S. ARMED FO CE37 <br />16. BGCIAL SECURIn No. <br />17. INFORMANT Address <br />(Ye <br />0 .ar unknown) (IJ yss.Vice waT or dates of esro;ce) <br />uny otm <br />III <br />T ea`), <br />/i/ml <br />15. CAUSE OF DEATH IEwsr only one cause I' M. a (C). A <br />INTERVAL BETWEEN <br />PART 1. DEATH WAS CAUSED BY: <br />IMMEDIATE <br />ONSET ANO PERTH <br />- <br />• l� <br />CondieiwM, iJ anY. ) W[ TO (b) 7 • -" r ( <br />/akteh gaN TIM to - <br />abase rattle <br />fly <br />stating the nder <br />e <br />d u <br />lying -iW lad. DUE TO (C) <br />S) EION1rICMIT OGNDITIONS CONTRIWTINO TO DEATH WT Noe RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN <br />PART /(a) <br />19. WAS AUTGPSY <br />VV4 <br />/ <br />y03S <br />IERrORM[O <br />YES° an° <br />208. ACC DENT SUICIDE HOMICIDE <br />Rob. DESCRIBE NOW INJURY OCCURRED. (Enter nature of injury in Part I ar Part II of Item 18.) <br />( ° ° <br />L i ; OCY MORTUARY <br />• - / <br />no. TIME of Hour Month, DOW, Yaw A _ <br />Z <br />INJURY a•mj C� <br />- <br />_ �. '2-0191 CGiiONEHS OFFICE <br />` L .S r' ` <br />,INJURY <br />Md. OCCURRED 200. PLACE OF INJURY (e.g., in or about f. CITY, TOWN. OR LOCATION COUNTY STATE <br />WNR.E'AT NOT WHILE home, far , factory, Bred, office bldg.- <br />WORK AT WORK S doJ- �t <br />Ll� <br />.= .Ct.,tT1' b1.L / <br />w <br />21.. ? attended the deua/ed from / �- / t7 - ' , to - ! t S �. and lad saw him aline on <br />DtWA oaurrd a< f m. on the date stated about and to the best of my knowledge, from the causes stated. <br />22a. SIGNATURE ) (Degree or title) <br />22Is. ADDRESS <br />220, DATE SIGNED <br />238. MIMAL, CREMATION, <br />23b. DATE <br />234. NAME QF CEMETERY OR CREMATORY <br />d. LOCATION (City, Iowa. or county) (State) <br />.REMOVAL (S i/Y) <br />- -1 <br />- -- -Salina <br />- - -- <br />l�eova _). <br />an. l <br />tg <br />Kansas <br />2O. DIR[ ADORES! <br />25. DAY[ RECD. BY LOCAL REG. <br />26, REGI TRAR'S SIGN TUR <br />I <br />r'Na, SS: <br />T Pjereby certify that the above is a true, full and correct copy of <br />die` original certffleate in iV custody and now on file in IV office. <br />sp hand'?ap gfficial seal at Denver, in said State, this <br />1959. <br />a DIRECTOR OF STATE PARn ENT OF C <br />i <br />' }� STATI <br />e <br />`3, <br />--e <br />