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bfV a CERTIFICATION OF VITAL RECORD <br />1d 1III1IVr_ili ^` rl11,111 110 <br />CERTIFICATE OF DEATH STATE FII eNUMBER 105202004190.1 <br />DECEDENTS LEGAL NAME <br />ALFRED ALLEN MCCALLA <br />SOCIAL SECURITY NUMBER: AGE -Last Birthday (Years) <br />IF DEATH OCCURRED IN HOSPITAL <br />INPATIENT <br />DECEMBER 01, 2020 <br />DATE -OF BIRTH (Ma/Day/Yr) <br />NOVEMBER 19, 1947 <br />IF DEATH'OCCIIRRED SOMEWHEREOTHERTHAN A HOSPITAL;:" <br />Facility Name (If not institution. give street 4;number) <br />MEDICAL CENTER OF THE ROCKIES <br />RESIDENCE - STREET AND NUMBER. <br />934 3RD STREET <br />BIRTHPLACE (Stateor.Foreign Country) <br />COLORADO <br />CITY, TOWN OR LOCATION OFDEATli :. COUNTY Of <br />LOVELAND lAR1MER "::.:.:.. <br />ZIP CODE <br />INSIDE CITY LIMITS <br />DECEDENTS USUAL OCCUPATION (Give kin work done during ,MOst of.wo,dng life. Dd not use retired) <br />TRUCK DRIVER <br />DECEDENT OF HISPANIC ORIGIN <br />NO <br />EVER IN US ARMED FORCES <br />YES <br />FATHER'S NAME <br />ALBERT MCCALLA <br />CITY DRTOWN ' <br />CHAPPELL <br />KIND OF BUSINESS/INDUSTRY DECEDENTS -EDUCATION <br />TRANSPORTATION 9TH -12TH GRADE, BUT NO DIPLOMA <br />MARITAL STATUS AT TIME OF DEATH <br />DIVORCED <br />:.: MOTHER'S NAME PRIOR TO FIRST MARRIAGE <br />EDNA PETRIE <br />INFORMANTS NAME. <br />ANNA MARIE PARKS• <br />NAMEOFFUNERAL HOME <br />MILE HIGH FAMILY SERVICES AKA MILE HIGH EMBA).MINQ AND $HIPPING, <br />INFORMANTS REtATIQNBHIP TO DEEA..SEP <br />tlAUGHTR <br />CITY AND STATE OT FUNERAL HOME_I" .` <br />DENVER COLORADO <br />METHOD OF DISPOSITION PLACE OF DISPOSMION `. <br />REMOVAL FROM STATE FORT MCPHERSON NATIONAL CEMETERY: <br />INJURY AT WORK: <br />IF 'TRANSPORTATION RELATED, SPECIFY <br />LOCATION::Vcfrfi COUNTY, STATE <br />MAXWEL41NCQ0 NEBRASKA <br />DATE OF:INJURY <br />LOCATION OF INJURY (Street 8 Number, Apt. No.; City or•;Tpwn, Cguiity,State, <br />DESCRIBE HOW INJURY OCCURRED -: <br />WAS DECEDENT. UNDER HOSPICE CARE <br />ACTUAL:612 PRESUMED .rind E:OF DEATH <br />Q.Z: 3'MIL <br />MANNER OF DEATH <br />NATURAL <br />IMMEDIATE CAUSE (Final disease Or-' <br />condition resulting in death) <br />Sequentially list conditions, If 0ny, <br />leading to the cause listed on line a. <br />Enter the UNDERLYING CAUSE <br />(disease or injury that initiated the <br />events resulting In death) .. _ <br />DATE P'RONOUNGED.QEAP.(MO/DAY/yR).. <br />DECEMBE,R0T, 2020 <br />TIME PRONOUNCED - DEAD;'.:.: <br />02:23 MIL - <br />WAS AN AUTOPSY PERFORMED WERE .AUTOPSY FINDINGS CONSIDERED IN:DETERMINING <br />'2 THE cAUSe OF DEATH? <br />CAUSE OF DEATH <br />Enter:the-LJiatn of evenigieliseaSed fnjiueies: er.compllcetione-tterldireCtiy caused the death. <br />$ : ACUTE HYPDXIG:RR SP1RAtORY`AJLUt3E ' <br />PART. II Enter othersignificant contlitior)J: contribgting to death but not resulting in the underlying cause given in PART 1: -? <br />PEA ARREST, SEPSIS, ACUTE KIDNEY INJURY,: SHOCK <br />_. . . <br />TITLE, NAME: ADDRESS, ZIP CODE AND COUNTY OF PIYY.SICIAN:>.:. <br />JAMES D HOYT MD 2121 E HARMONY ROAD STE 300 FORT COLLINS CO 80525 <br />TITLE, NAME. ADDRESS. ZIP CODE AND COUNTY OF CORONER <br />DATE FILED BY REGISTRAR <br />DECEMBER 04, 2020 <br />DATE StCNEti • <br />DATE. ISSUED DECEMBER 10, 2020 <br />THIS IS. A TRUE CERTIFICATION OF NAME AND FACTS AS <br />RECORDED IN THIS OFFICE; : Do not accept Inness prepared on <br />securitypaper_with:engraved border displaying the Colorado stateseal <br />and signature of the Registrar: PENALTY BY LAW, Section 25-2,-.11g, <br />Colorado Revised Statutes;1982, if a person alters, u§es, attempts to <br />use .orfurnishes to ane for deceptive use any vital statistics record <br />NOT VALID IF PHOTOCOPIED. <br />A. ALEX QUINTANA <br />STATE REG STRAR <br />