|
1. DECEDENTS NAME (Fast, Middle, Last)
<br />James Lee BONHAM
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Month, Day, Year)
<br />August 28, 2013
<br />4. SOCIAL SECURITY NUMBER
<br />497 -24 -6187
<br />5a. AGE -
<br />(Years)
<br />86
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH
<br />Month Day Year.
<br />April 07, 1927
<br />7. BIRTHPLACE (City and State or Foreign Country)
<br />Springfield, Missouri
<br />Moa Days
<br />Hrs Mins
<br />8. WAS DECEDENT EVER
<br />IN U.S. ARMED FORCES?
<br />0 Yes Ca No
<br />9a. PLACE dF DEATH (Check only one)
<br />HOSPITAL: OTHER: ASoisted Uvin Nursin Home Hospice ❑ 9 9 ❑ H lu II Decedent's Residence
<br />® Inpatient IN ER/Outpatient ❑ DOA ❑ Other (Specify)
<br />9b. FACILITY NAME (If not institution, give street and number)
<br />Anschutz Inpatient Pavilion J UCH
<br />9c. CITY, TOWN, OR LOCATION OF DEATH
<br />Aurora
<br />9d. COUNTY OF DEATH
<br />Adams
<br />, 10a. DECEDENTS USUAL OCCUPATION (Give land of work
<br />I done during most of working life. Do NOT use retired)
<br />Anthropologist
<br />1011. KIND OF BUSINESSINDUS TRY
<br />Education
<br />11. MARITAL STATUS
<br />Married B Never Married
<br />u � Dwr°ed
<br />12. SPOUSE (If wife, give maiden name)
<br />Jennifer I. Hacker
<br />; 13a. RESIDENCE - STATE
<br />1
<br />Nebraska
<br />13b. COUNTY
<br />Hall
<br />13c. CITY, TOWN, OR LOCATION
<br />Grand Island
<br />..
<br />13d. STREET AND NUMBER
<br />2617 Brahma St.
<br />13e. INSIDE CITY LIMITS?
<br />' Yes 0 No
<br />®
<br />13f. ZIP CODE
<br />68801
<br />14. WAS DECEDENT
<br />"Yes", specify
<br />Da No
<br />DYes specif
<br />OF HISPANIC ORIGIN?
<br />Cuban, Mrdcan, Puerto Rican, etc.)
<br />15: RACE American Indian, Black, White, etc.
<br />( Specfy)
<br />White
<br />16. EDUCATION: (Specify only hlIg� ttesta ede
<br />co or seoonaary (0 12)
<br />CoAege' (13.16 of 17+
<br />17
<br />17. FATHER - NAME (First, Middle, Last)
<br />Griffith Bonham
<br />18. MOTHER- NAME (First, Middle,
<br />Mildred Koch
<br />Maiden)
<br />19. INFORMANT - NAME and relationship to deceased
<br />James J. Bonham, Son
<br />20a. METHOD OF DISPOSITION 0 Resomation
<br />0 BudaVEntombmeni Cremation ❑ Removal . to
<br />0 Donation ()Other (Specify)
<br />20b. PLACE OF DISPOSIi ON (Name of cemetery, crematory, or other.
<br />Color -lo Crematory Services
<br />20c. LOCATION - City or Town, State
<br />Wheat Ridge, Colorado
<br />21a. SIGNATU rF ERAL DIR eR e ' PERSON ACTING AS H
<br />�Igneteltsa o
<br />gib. NAME AND ADDRESS OF FACILITY
<br />Olinger Hampden Mortuary
<br />8600 E. Hampden Ave. Denver, CO 80231
<br />STPC t .
<br />1 8g RA SSJE
<br />T
<br />I
<br />b DAT1 FILED (Mordh, Day,�ar)
<br />AUG 3 0 2013
<br />23.T1MEOFDEATH 0427
<br />❑ AM ❑ PM §4 milt
<br />24. DATE AND T(MEPRONOU
<br />Month Day Year Time
<br />August 28, 2013 0427 ❑ Am O PM ® Mtt
<br />i
<br />25. WAS CORONER NO
<br />izt Yes ❑ No
<br />TO BE COMPLETED BY SIGNING PHYSICIAN
<br />TO BE COMPLETED CV CORONER
<br />26a. To the best of my knowledge death occurred at the time, date and
<br />place, and due to the cause(s) and manner as stated.
<br />//� A MD
<br />Signature l,N• (L 4V „ DO
<br />27a. On the basis of exan and/or investigation, in
<br />at the time, date and place, and due to 'opinion death ocourred
<br />f se(s) and manner as stated.
<br />Signatures El Coroner
<br />❑ Assoc/Deputy Coroner
<br />26b. DATE SIGNED (Month. D ,ear)
<br />August 28, 2013
<br />27h DATE SIGNED (Month, Day. Year)
<br />26c. NAME, AND MAILING ADDRESS OF SIGNING PHYSICIAN
<br />Mary Anderson MD
<br />University of Colorado Hospital
<br />12605 E. 16th Ave.,Aurora,i Colorado 80045
<br />27c. NAME AND COUNTY
<br />28. NAME OF AtIENDING PHYSICIAN IF OTHER THAN SIGNING PHYSICIAN
<br />29. MANNER OF DEATH
<br />E Natural ['Accident ❑Suicide
<br />Homicide 0 Pending Investigation
<br />❑ Undetermined
<br />30. DID TOBACCO USE CONTRIBUTE TD DEATH
<br />0 Yee 10 No °Probably 13 Unknown
<br />31. IF FEMALE
<br />❑ Not Pregnant last year Q Not pregnant, but pregnant 43 days to 1
<br />❑Pregnant at time of death year before death
<br />O Not pregnant, but pregnant within 42 days M death 0 Unknown it pregnant within the past year
<br />32a. DAVE OF INJURY (Month, Day, Year)
<br />32C(IME OF INJURV
<br />ID AM 0PM O Milt
<br />32c. INJURY AT WORK?
<br />❑ Yes 'ONO
<br />32d. DESCRIBE HOW INJURY OCCURRED
<br />32e. PLACE OF INJURY - At home, farm street, factory, office building, etc. (Specify)
<br />321. LOCATION INJURED (Street and Number or Rural Route Number, Oily, Courtly, State)
<br />33. IMMEDIATE CAUSE - enter only one cause per line for (a), (b), and (c). Do not enter mode of dying (e.g. Cardiac or Respiratory Arrest) alone.
<br />Part1. (a) Acute Hypoxic Respiratory Failure
<br />Interval between onset and death
<br />Days
<br />which gave rise DUE TO OR AS A CONSEQUENCE OP t
<br />oi causestaalin Pulmonary mboli
<br />cause sting the (b> y
<br />interval between onset and death
<br />Days
<br />underlying cause DUETOOryASA CONSEQUENCE OF:
<br />last (o) (°) Aspiration Pneumonia
<br />Interval between onset and death
<br />Days
<br />Y
<br />Part 2. OTHER SIGNIFICANT CONDmONS - Conditions contributing to death but not related to cause in Part 1
<br />Acute Renal Failure; Pancreatic Cancer; Subdural Hematoma; Diabetes
<br />34. AUTOPSY
<br />DYes i3N°
<br />33.1iYES, were findings considered
<br />M determining cause of death?
<br />■Yea ■ N°
<br />r`t fr .
<br />,z 'R
<br />'F CERTIFICATION OF VITAL RECORD
<br />'ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE
<br />in
<br />DATE ISSUED AUG 3 0 2013
<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 />AIDerloanBanlcNote('Ampaaig
<br />STATE OF COLORADO
<br />COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
<br />HOLD TO LIGHT TO VIEW WATERMARK
<br />STATE OF COLORADO
<br />CERTIFI OF DEATH
<br />RONALD S. HYMAN
<br />STATE REGISTRAR
<br />1111111111 III I11
<br />201505891
<br />
|