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STATE OF COLORADO
<br />STATE OF COLORADO STATE FILE NUMBER
<br />200 0 0 6 5 9 CERTIFICATE OF DEATH
<br />I . DECEDENT'S NAME First. Middle. Last) 2. SEX 3. DATE OF DEATH (Month. Day, Year)
<br />Elva Irene GRUNKEMEYER Fe August 6, 1999
<br />4. SOCIAL SECURITY Sa. AGE Last Sb. UNDER 1 YEAR Sc. UNDER t DAY - 6. DATE OF BIRTH 7. BIRTHPLACE (City and State or Foreign
<br />NUMBER Birthday IYearsl (MOn Ih, Day, Year) Country)
<br />508 -66 -4416 91 aye Hra M105 April 2, 1908 Hastings, NE
<br />B. WAS DECEDENT EVER IN 9a. PLACE OF DEATH (Check onlyone)
<br />U.S. ARMED FORCES? HOSPITAL: r OTHER
<br />O Yes XNo D Inpatient D ER /Outpatient D DOA r ❑ Nursing Home * Residence D Other (Specify)
<br />9b. FACILITY NAME (11 not institution, give street and number) 9c. CITY, TOWN, OR LOCATION OF DEATH go. COUNTY OF DEATH
<br />10000 E. Yale Ave. 1140 Denver Denver
<br />10a. DECEDENT'S USUAL OCCUPATION 10b. KIND OF BUSINESS /INDUSTRY 11. MARITAL STATUS - Marrietl, 112. SPOUSE (It wife, give maiden name) ,
<br />Give kind of work done during most of working file. Never Married. Widowed,
<br />P not use retired.) Divorced (Specify)
<br />Carl
<br />Homemaker Own Home Widowed A. Grunkemeyer-
<br />13a. RESIDENCE -STATE I 13b. COUNTY 13c. CITY, TOWN, OR LOCATION 13d. STREET AND NUMBER
<br />CO Denver Denver 10000 E. Yale Ave. #40
<br />13e. INSIDE 13, ZIP CODE 14. WAS DECEDENT OF HISPANIC ORIGIN? 15. RACE American Indian, 16. DECEDENT'S EDUCATION fSpecily only highest
<br />CITY (Specify No pr Yes - 1f yes..specily Cuban, Black White; elA.Zoo, /y) gyrade completed) Elementary or secondary
<br />LIMITS? exican, Puerto Rican, etc.) - 10 fhrouph 12)Collage (13 through 16 or 17 +)
<br />ffi Yes S No O Yes
<br />❑ No 802.31 SPecrry:
<br />White 16+
<br />17, FATHER -NAME (First, Middle, Last) 18. MOTHER -NAM (F,,sL Middto, LasftMaid&n Namo)I 9. INFORMANT-NAME and relationship to deceased+
<br />Clifford McWhirter Zora Lee.Ballagh Shirley Costello- Daughter
<br />20a. METHOD OF DISPOSITION 20b. PLACE OP. DISPOSITION (Mafia W camefely, crematory, or 20c. LOCATION - City or Town, State
<br />O Burial XI Cremation O Removal from State other pfaEe).
<br />• •• •
<br />DDonaeon 0Other(Specify) ,Horan ,& Zcjponaty 'Crematory Denver, CO
<br />2 L. SIGNATURE UNERAL DIRECTOR ORPERBON ACTING AS SUCH 21b. NAME ANOAODRESSOF FACILITY:
<br />► Horan & McConaty Mortuaries
<br />3201 Sp. Parker Rd. Aurora, CO z)p:80014
<br />22a. REGISTR NATU E 22b. DATE FILED (Month, Deg Y• Irl _ _
<br />O.M AUG 13 L%]C]
<br />23. TIME OF DEATH 24. DAT RONOUNCED DE �( 25. WAS CORONER NOTIFIED?
<br />Month y'Yeer22,lOour (Yes orNo) Yes
<br />8:00 P.M August 06 1999 9
<br />TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN.. TO BE COMPLETED BY CORONER
<br />26. To the best of knowledge, death occurred at the time, date and placeiand du aid 27.. On the basis of examination and /or investigation, in my opinion tleath occurred at the
<br />the cause(s) en manner as staled. time, dateand place, and due to the causes) and manner as stated.
<br />Signature ► Signature 00.
<br />20. DATE SIGNED IM nth, Day, Year) - 29, DATE SIGNED (Month, Day, Year)
<br />2 OZ4
<br />30 NAME. TITLE AND MAILING ADDRE_SSS OF - CERTIFIER/CORONER (Type /Phrif) / ? (`� r
<br />9 /��h - JJ700 ,GOB Ce ZIP:a `0��O
<br />31. NAME OF ATTENDING PHYSIC16M IF OTHER THAN CERTIFIER IType /Print)
<br />4 - 2. MANNER OF DEATH 33a. DATE OF INJURY 33b. TIME OF 33c. INJURY 33d. DESCRIBE HOW INJURY OCCURRED
<br />�� (Month, Day. Ys•r) INJURY WORK ?.
<br />dlgmural D Pending D Yee D No '
<br />5 Investigation M
<br />D Accident
<br />D Suicide D Undetermined
<br />Manner 33•. PLACE . e WJURY'-At home, farm, etrea4 factory. office 331. LOCATION IStroet and Number or Rural Route Number, City, Count', State)
<br />building. •tc.(Speclly)
<br />O Homicide
<br />34. IMMEDIATE CAUSE IENTERONLtDME CAUSE PER LINE FpR (el, ! . AN (r l.i Do not snl mods of dylnp (e.g. Cardiac or Respiralory Arrset)el°ne. Interval between onset
<br />PART / -/ t0; 1,ar1 a tleath
<br />s CONDITIONS DUE TOOR AS CONSEQUENCE OF lmery between onset
<br />IF ANY WHICH and death
<br />GAVE RISE TO Ib) G C� U/7 of
<br />IMMEDIATE CAUSE DUE TO OR AS ACONSEOUENCE OF
<br />STATING THE Int de between onset
<br />UNDERLYING CAUSE and death
<br />LAST (c) (c)
<br />PART OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not related to cause in 135. AUTOPSY 36. IF YES were findings considered
<br />II PART I (e.g, alcohol abuse, obesity, smoker). (Yea or No) In determining cause of death?
<br />21le'I,- / c No
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL WCORD WHICH IS IN MY CUSTODY.
<br />], 6 -1, 8 3 8 [A"s -1 a 1.89 (Rev. 1.91)
<br />DATE ISSUED
<br />LOCAL REGISTRAR JJ
<br />i
<br />Do not accept unless prepared on security paper with engraved border displaying the Colorado state
<br />seal and signature of the Registrar. PENALTY BY LAW, Section 25 -2 -118, Colorado Revised `
<br />�C Statutes. 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use
<br />anv vital statistics record. NOT VALID IF PHOTOCOPIED. i
<br />��._ ,�s:�� , :.__ = of.arrAaa. -._ _. -. arefi�PkRra„ -•�^.r.e�Afi,�.. �'
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