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1. DECEDENT'S NAME (First, Middle, Last)
<br />Marvin Ellis BROWN
<br />4. SOCIAL SECURITY NUMBER
<br />507 - 16 - 9914
<br />B. WAS DECEDENT EVER
<br />IN U.S. ARMED FORCES? HOSPITAL:
<br />® Yes ❑. No ❑ Inpatient ER/Outpatient
<br />9 . ILI A pot Institution, glue street an num•e
<br />Columbine Care Center West
<br />10a. DECEDENT'S USUAL OCCUPATION (Give kind of work
<br />done during most of working life. Do NOT use retired)
<br />Manager
<br />13a. RESIDENCE STATE
<br />Nebraska
<br />13e. INSIDE CITY LIMITS?
<br />® Yes ❑ No
<br />17. FATHER -NAME (First, Middle, Last)
<br />Frank Brown
<br />21a. SIGNATURE 0g DIRECTOR 9R PERSON ACTING AS SUCH
<br />23. TIME OF DEATH
<br />8:42
<br />❑ AM ® PM ❑ Miit
<br />TO BE COMPLETED BY SIGNING PHYSICIAN
<br />26. Tome best
<br />place, and due to
<br />Signature
<br />nowledge, death occurred at the time, date and
<br />use(s) and man r as sta -d.
<br />r C! I ��
<br />26c. NAME, AND MAILING ADDRESS OF SIGNING PHYSICIAN
<br />David K. Allen, M.D.
<br />305 Carpenter Road
<br />Fort Collins, CO 80525
<br />9. MANNER OF DEATH
<br />t ❑ .} , Natural ❑ Accident ❑ Suicide
<br />Homicide ❑ Pending Investigation
<br />❑ Undetermined
<br />32a. DATE OF INJURY (Month, Day, Year)
<br />32e. PLACE OF INJURY - Al home, farm, street, factory, office buildi g, (p y)
<br />33. IMMEDIATE CAUSE enter only ne
<br />Part 1. (
<br />Contlitions if any DUE TO OR AS A
<br />which gave rise
<br />to immediate
<br />cause stating the (b)
<br />5a. AGE -
<br />(Years)
<br />89
<br />13b COUNTY I
<br />Hall
<br />32b.TIME OF INJURY
<br />❑ AM ❑ PM ❑ Milt
<br />5b. UNDER - 9 : YEAR
<br />5p. UNDER DAY
<br />Hre „<Mms
<br />105. KIND OF BUSINESS /INDUSTRY
<br />Dry Cleaning
<br />13c. CITY, TOWN, OR LOCATION
<br />Grand Island
<br />13f.ZIP CODE
<br />68801
<br />14. WAS DECEDENT OF HISPANIC ORIGIN?
<br />(If Wes ', specify Cuban, Mexican, Puerto Rican, att.)
<br />®No
<br />DYes. Specify:
<br />24. DATE AND TIME PRO DEAD
<br />Monet
<br />February 13 2013 8:42
<br />30. DID TOBACCO USE CONTRIBUTE TO DEATH
<br />Ores ID No E3 Probably 01 Unknown
<br />Part 2. OTHER SIGNIFICANT C Conditions contribulkig to death 5u of (etatedd o ca m Part 1
<br />•
<br />2. SEX
<br />Male
<br />6. DATE OF BIRTH
<br />Month Day Year
<br />December 29, 1923
<br />® Assisted Living/Nersing Home ❑ Hospice
<br />❑ Oth.i
<br />9c, CITY, sWN • •N •F
<br />Fort Collins
<br />❑; DOA
<br />BEATH
<br />11. MARITAL STATUS
<br />l Married ID Never Married
<br />a Widowed E] Divorced
<br />Unknown
<br />15. RACE: American Indian, Sleek,
<br />(Specify)
<br />White
<br />ite, etc...
<br />18. MOTHER- NAME. (First, Middle, Maiden)
<br />Estella Swindle
<br />206. PLACE OF DISPOSITION (Name of cemetery, crematory , or other
<br />DIaC9d)
<br />20e. METHOD OF DISPOSITION 0 Resomabon
<br />❑ BunallEntombment ❑ Cremation ® Removal from State
<br />1:1 Donation ❑ Omer (Specify)
<br />EDAM . . ra PM
<br />7. BIRTHPLACE (City and State or Foreign Country)
<br />Lewellen, NE
<br />9a. PLACE OF DEATH (Check only one)
<br />❑ Decedent's Residence
<br />9d. COUNTY OF DEATH
<br />Larimer
<br />12. SPOUSE (If wife, give maiden name)
<br />Dolores Jean Moore
<br />13d. STREET AND NUMBER
<br />208 East 17th Street
<br />16. EDUCATION: (Specify only highest grade
<br />completed) Elemena or secondary U
<br />College (13 -16 or 170)
<br />19.INFORMANT- NAME and relationship to deceased
<br />Dolores J. Brown - Wife
<br />20o.LOATION City or Town, State
<br />Grand Island, NE
<br />21b. NAME AND ADDRESS OF FACILITY
<br />Allnutt Funeral Service Drake Chapel
<br />650 W. Drake Rd
<br />Fort Collins, CO 80526
<br />I22a. REGISTRAR'S SIGNATURE
<br />1 }\� / r, F 22b. DATE FILED (Month, Day,Year)
<br />r� ✓/� ( : � y( - i 1 _ / , V t / � n . February 15 , 2013
<br />3. DATE OF DEATH (Month, Day, Year)
<br />February 13, 2013
<br />25.WAS CORONER NOTIFIED?
<br />❑ Yes ®No
<br />TO EP COMPLETPD RY: LORrlNFR
<br />27a. O0 the basis of examination and/or investigation, in my opinion death occurred
<br />at the me date and place, and due to the cause(s)and manner as stated.
<br />El Coroner
<br />Signs {We � ❑ e c000veputyCoroner
<br />Year?
<br />273. DATE SIGNED (Month, Day, Yea,
<br />27c. NAME AND COUNTY
<br />28. NAME OF ATTENDING PHYSICIAN IF OTHER THAN SIGNING PHYSICIAN
<br />31. IF FEMALE:
<br />❑ Not pregnant vnlmnlast year Y Not pregnant, but pregnant 43 days tot
<br />❑ Pregnant at time of death: year before death
<br />Not pregnant but pregnant within 42 days of death El Unknown d pregnant within the past year
<br />32c. INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
<br />n etc. S 01)
<br />❑ Yes ❑ No
<br />32f. LO ATION INJURED (Street and Number or Rural Route Number, City, County, State)
<br />use per litre for (a), ((6), , 006 (0). Do not enter mode of dying (e.g. Cardiac or Respiratory Arrest) alone.
<br />y
<br />underlying cause
<br />last (c).
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />3 4. AUTOPSY
<br />I] Yes ® No
<br />Interval between onset and death
<br />Interval between onset and death
<br />35. IF YES were findings considered
<br />in determining cause of death?
<br />D Yes ❑ No
<br />132 -135
<br />DATE ISSUED
<br />COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
<br />HOLD TO LIGHT TO VIEW WATERMARK
<br />THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS
<br />RECORDED IN THIS OFFICE. Do not accept unless prepared on
<br />security paper with engraved border displaying the Colorado state seal
<br />and signature of the Registrar. PENALTY BY LAW, Section 25-2-118,
<br />Colorado Revised Statutes, 1982, if a person alters, uses, attempts to
<br />use or furnishes to another for deceptive use any vital statistics record.
<br />NOT VALID IF: PHOTOCOPIED.
<br />MANY ALTERATION OR ERASURE VOIDS TH(S CERTIFICATE'
<br />.22227 tIVattata22272.22.2222272J222:
<br />s CERTIFICATION OF VITAL RECORD
<br />_
<br />STATE OF COLORADO
<br />CERTIFICATE OF DEATH
<br />FEB 15 2013
<br />RONALD S. HYMAN
<br />STATE REGISTRAR
<br />STATE FILE NUMBER
<br />0 0 6 3 2 2 3 6 0
<br />REV 01/07
<br />s ?'
<br />° a' y
<br />Iii
<br />:s't4Y1r
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