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STATE OF COLORAD
<br />C ERTIFICATION OF VITAL RECO
<br />� SrNa - Ni7M
<br />1. DECEDENT'S NAME (First, Middle, Last) 2. SEX 3. DATE OF DEATH (Month, Day, Year)
<br />Naomi O. Cox SEEMAN Femele `September 22, 2015
<br />4. SOCIAL SECURITY NUMBER 5a. AGE 5b. UNDER 1YEAR SC..UNDER 1 DAY 6. DATE OF BIRTH 7. BIRTHPLACE (City and State or Foreign Country)
<br />.(Years) Mos Days Hre ,: Mms Month Day Year
<br />265 -55 -3212 ` 57
<br />April 14 - 1 958 Washington
<br />8. WAS DECEDENT EVER 9a. PLACE OF DEATH (Gluck only one)
<br />IN U.S. ARMED FORCES? HOSPITAL: OTHER: e 9
<br />Assisted Liv 7 Nwsin Home ❑ Hospice � Decedent's R esidence
<br />❑ Yes Q No ' Q - Inpatient • ER /Outpatient DOA J Other (Specify)
<br />9b. FACILITY NAME (1 not institution,: give street and number) 9c. CITY, TOWN, OR L ATION OF DE 9 'COUNTY OF DEATH
<br />r St. Anthony Hospital Lakewood Jefferson
<br />1 Oa. DECEDENTS USUAL OCCUPATION (Give kind of work 11 . KIND ✓ tF BUSINESS/INDUSTRY 11.MARITAL STATUS 12. SPOUSE. (8 wife, give maiden. name)
<br />done during most of working life. Do NOT use retired) Named Never Mauled
<br />CEO Medical Administration LJWidowed Divorced-
<br />i Unk wv rs Terrance Seeman
<br />13a. RESIDENCE -STATE 12b. COUNTY 1 3c. CIT'Y TOWN, OR LOCATION 1ad. STREET AND NUMBE
<br />1
<br />Nebraska Hall Grand. Island 422 Rosewood Circle
<br />3e. INStDE CITY LIMITS? 131. ZIP. CODE 44. WAS DECEDENT OFHISPANICO1R5N? t5,RACE: Ayneruanlridian,Black, White, etc 16. IU 1• peel only Ng estgrade
<br />E .� "Yes specify Cuban, Mexican, Puerto Rican, etc) (Specify): complet64) Elementary or secondary ( 6- 12)
<br />(� 0 Yes 0 No �� No
<br />College 1 -16'ar 17 +)
<br />68803 0 Yes Specify: `' White - 17+
<br />17. FATHER - NAME (First, Middle, Last) 18. MOTHER NAME (First, Middle, Maiden) 9.1NFORMANT -NAME and'relationship to deceased
<br />L Maynard H. Cox
<br />Gloria Baer Terrance Seeman,
<br />+Oa. METHOD OF DISPOSITION- 0 Resomation ' 20b. PLACE OF DISPOSITION (Name of cemetery, crematory,. or other 20c. LOCATION - City or Town, State
<br />1:1 Buriel/Entombment 0 Cremation {] Removal from St a t e r ` Mace)
<br />El Donation DOther (Specify) Lake Crematory: Lakewood, Colorado
<br />21a. SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTINi.$ D
<br />.SUCH .' 21b. NAME ANADDRES' S OF FACILITY
<br />Signature � j Aspen'tVlortuary
<br />� ? 1350 Simms Street Lakewood Colorado 80401
<br />22e. REGIS7RA' 22b. DAT LED (Month, Day, Year)
<br />Signature i""` G/ n
<br />23.TIME 0 DEATH 24. DATE ANDTIME PR* . • 14CED 6 EAD : 25. WAS CORONER NOTIFIED?
<br />1640 Month Day Year Time
<br />El AM 0 PM 0 milt September 22 2015 1640
<br />Q:AM ❑ PM � Mgt..: 0 Yes ❑ No
<br />TO BE COMPLETED BY SIGNING PHYSICIAN
<br />TO BE COMPLETED BY CORONER
<br />26a.To the best of my knowledge, death occu • .. the time, date and ]� 27a. On the basis of examination and/or investigation, in my op'nion death occurred
<br />place, and due to the cause . j and manner as . - t D at the time, date and place, and due to the cause(s) and manner as stated.
<br />Signature ❑DO Signature ,. I] : Coroner
<br />261). DATE SIGNED (Mo , Day, Ye. r
<br />��` D - Assoc /Deputy Coroner
<br />� jy / 27b. DATE SIGNED (Month, Day, Year)
<br />26c. NAME, AND MAILING ADCRESS OF SIGNING PHYSICIAN ._ 27c. NAME AND COU
<br />" TFb�ia3 "&i vtit t "
<br />274 (n( i `Q Iv . $ IIO : : 28. NAM5 OFAI 1 ENNG PHYSICIAN IF OTHER THAN SIGNING PHYSICIAN
<br />• 0 SG .9"s
<br />9. MANNER OF DEATH 30. DID TOBACCO USE CONTRIBUTE TO DEATH 31. IF FEMALE:
<br />. tural ❑ Accident QSuiode ❑ Yes ❑ No P obably'lnown
<br />- [� � 0 Not pregnant Within last year
<br />[] Not pregnant but pregnan1 days To 1
<br />NI Homicide
<br />❑ Pending IsVestl 9 ahon (]Pregnant at time bf'death year before death
<br />■ Undetermined - - ❑ Not pregnant, but pregnant within 42 days of death !4 Unknown 4 pregnant within the past year
<br />va. I ' . • ' I - • (Month Day, Year) 'r2b.TIME OF INJURY ' 32c.INJURY.AT WORK? 32.. DESCRIBE HOW INJURY OCCURRED
<br />■ AM QPM 0 Milt 0 : Yes 0 No
<br />32e. PLACE OF INJURY - At home, farm street, factory; office buil etc. (Specify) 32t LOCATION INJURED (Street and Number or Rural lloute Number, City, County, State)
<br />33. IMMEDIATE CAUSE - enter onyone eau per line tor (a); ( and (c). Do no e t/ - ..e of dyin. (e.g. Cardiac or Respiratory Arrest) atone. Inter .1 between onset and death
<br />Part 1. (a) .: °. lyt p : •� ' < ..
<br />Conditions if any DUE TO OR'AS A CONSEQUENCE OF Interval bet . onset and death
<br />which gave rise
<br />to immediate
<br />cause stating the (b)
<br />underlying Cause :. OUETO GRAS A CONSEQUENCE 00 Interval between onset and death
<br />last (C). .. .
<br />Part 2. OTHER SIGNIFICANTCONDITIONS - Conditions contributing to death but not related to cause in Part f 34, AUTOPSY 3 5. if YES, were findings considered
<br />in determining cause 01 death?
<br />II Yee F4 No .' . l Yes • No
<br />DATF pu it
<br />THIS IS A ME OF NAME AND FACTS AS
<br />RECORDED IN T OFFICE. Do not accept unless prepared on
<br />security paper with engraved border displaying the Colorado state seal
<br />I% 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 />STATE OF COLORADO
<br />CERTIFICATE OF DEATH
<br />REV 08114
<br />e on w VMn ., ', o < 4 s a4'tis 'T o a s brbb vri'
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE �}
<br />QTATC CII CAll In ADG't1
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