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SEX <br />FEMALE <br />SOCIAL SECURITY NUMBER <br />506 -28 -3433 <br />IF DEATH OCCURRED IN HOSPITAL <br />INPATIENT <br />Facility Name (!f not institution, give street & number) <br />SCL HEALTH COMMUNITY HOSPITAL <br />RESIDENCE - STREET AND NUMBER <br />2415 IRVING STREET <br />RESIDENCE STATE <br />COLORADO <br />DECEDENT OF HISPANIC ORIGIN <br />EVER IN US ARMED FORCES <br />NO <br />FATHER'S NAME <br />AUGUST KRULL <br />INFORMANTS NAME <br />DELBERTA JONES <br />NAME OF FUNERAL HOME <br />NEWCOMER FUNERAL HOME & CREMATORY WEST' METRO CHAPEL' <br />'F t 0fS POS6$ION . '✓ �". <br />S i LAwN CEMETERY` <br />INJURY AT WORK IF TRAAISPOQTATION RELATED, SPECIFY <br />METHOD OF DISPOSITION <br />REMOVAL FROM STATE <br />PLACE OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />WAS DECEDENT UNDER HOSPICE CARE <br />MANNER OF DEATH <br />NATURAL <br />PART <br />DECEDENT'S LEGAL NAME <br />MILDRED IRENE CHAOWICK <br />IMMEDIATE CAUSE (Final disease or <br />condition resulting in death) <br />Sequentially list conditions, if any, <br />leading to the cause listed on line a. <br />Enter the UNDERLYING CAUSE <br />(disease or injury that initiated the <br />events resulting in death) <br />TITLE, NAME, ADDRESS, ZIP CODE AND COUNTY OF CORONER <br />DATE FILED BY REGISTRAR <br />NOVEMBER 07, 2016 <br />CERTIFICATE OF DEATH <br />AGE -Last Birthday (Years) <br />88 <br />UNDER 1 YEAR <br />Months <br />COUNTY <br />DENVER <br />b COR PULMONALE <br />TITLE, NAME, ADDRESS, ZIP CODE AND COUNTY OF PHYSICIAN <br />KATARZYNA K CRABTREE MD CPO 535 16TH STREET 750 DENVER CO 80202 <br />DECEDENT'S USUAL OCCUPATION (Give kind of work done during most of working life. Do not use retired) <br />HOMEMAKER <br />UNDER 1 DAY <br />LOCATION OF INJURY (Street & Number, Apt. Na . '._ ity or Town, Coietty,'State, ZipCode) r„ <br />Minutes <br />IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL <br />CITY, TOWN OR LOCATION OF DEATH <br />WESTMINSTER <br />PART Il Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART t <br />INTERSTITIAL LUNG DISEASE <br />DATE ISSUED NOVEMBER 08, 2016 <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 high resolution border displaying the Colorado state <br />seal 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 fumishes to another for deceptive use any vital statistics record. <br />NOT VALID IF PHOTOCOPIED. <br />KIND OF BUSINESS/INDUSTRY <br />OW?4 HOME <br />— ' <br />9IOUAE/PAR R'4 W.'E/(If tttesre g me prior Wend <br />DEL BFRT$.�J vK <br />-.:.M{THER'SNAMffRAID- Tt. Fe=t4TAAARRIAGE <br />ti / ,OLA HAZ✓rt FUt 4E,A <br />1r4✓=ORMANTSREt*TJ0 L! ° TO DEV..ASED <br />4 ' <br />'21'Y—AND ,STA fEoF FUNEf� H�.7 <br />t. AKEWQOD GOLI:Arn 9 <br />REV 04/16 <br />DATE OF BIRTH (Mo/Day/Yr) <br />MAY 07, 1928 <br />DATE OF DEATH <br />OCTOBER 27, 2016 <br />COUNTY OF DEATH <br />JEFFERSON <br />APT. NO <br />CITY OR TOWN <br />DENVER <br />INJURY <br />( <br />G; U OF 6EATH <br />Enter the chain of eoF - sou - aniunes, u[ hednelications -that directly caused the death. <br />a ACUTE RESPIRATORY FAILURE' • <br />BIRTHPLACE (State or Foreign Country) <br />NEBRASKA <br />ZIP CODE <br />80219 <br />DECEDENTS EDUCATION <br />8TH GRADE OR LESS <br />LOOX" - ,COUNTY,STATE <br />GRA1lt' ISLAND HALL NEBRASKA <br />I TIME OF INJURY <br />INSIDE CITY LIMITS <br />YES <br />WAS CORONER NOTIFIED <br />YES <br />'ACTUAL OR PRESUMED TIME F , AT'1= PR to 1=D DE '.1:NL 4' R} TIME PRONOUNCED DEAD <br />#4..40.6m. z , ,,, 14:40 MIL <br />- AUTOPSY PER FORM 13* a - WER E E i5Jf0PSY FINDINGS CONSIDERED INDETERMINING <br />THE CAUSE OF DEATH? <br />t <br />DATE SIGNED <br />NOVEMBER 07, 2016 <br />DATE SIGNED <br />1 <br />