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CERTIFICATION OF VITAL RECORD /I <br />ATE OF:IDEA <br />DECEDENT'S LEGAL NANIE::�.';-� <br />CARE RDBERT..,BECKSTROM <br />IF DEATH OCCURRED IN HOSPITAL;;:," <br />INPATIENT <br />FaotWNan4:onpt)n ' tion, give street'&-numher) <br />AVISTA ADVENTIST HOSPITAL: <br />DECEDENTS USUAL OCCUPATION (Gweklndf Work don'i :during:ntiost <br />REGIONAL PRESIDENT <br />DECEDENT OF HISPANIC ORIGIN <br />NO <br />FATHER'S'NAME'l r <br />ROSE RT'OARt:: BECKSTROM; <br />METHOD OF DISPQS)TiON <br />CREMATION <br />INJURY Ai:woR1C '.. <br />LOCATION OF INJURY (Street & Number, Apt Nits <br />MANNER QF:PEATH <br />IMMEDIATE CAUSE (Filial disease a'.' <br />condition resulting in death) <br />:.SequsnkatIy I s ,co dohs, 't any.,'--• <br />.lea —to —to the tiausealsfed on tree a._ <br />:'Enter:ihe UNDERLYING CAUSE .. <br />(disease'orIrr)ury tbetkiltiate44h5..: <br />events resulting in'ddath) <br />TEO, SPECIFY <br />CtiRRED:SOMEWH <br />'C1TY'''TQWN OR <br />LOUISVILLE <br />)EL <br />PART:Ii Eriter:other..:sionificant`coriditioiucantributinst to death bat not resulting in theUrltlertyirl'g baUa8 <br />IMMUNE $UFPRESSION FROM M:;$r TRRA7Tv10NT; SMOKING,•OBESIfY <br />TI,TIIE, NAME, AO3RESS, ZIP C©PEANDCOUNTYpF Pliig� TAN <br />IA ES I c t s 1420 W MID . Y BO : VAR s' B ` IDO IEED CO 50020 <br />TITLE, NAME, ADDRESS, ZIP CODE AND COUNTY OFi;':i3RONER::`:::G(1`.'• , ;';:::;�•;•:`f' ��:"` <br />`av REO(S'.l`•hAR <br />PAxh.ISSUED DECEMBER <br />C4#iS IS A TRUE OERT XCAiION OF NAME AND FACT <br />`RECOEDED.TN THIS OFFICE ::Do not Neeprt;uiiless: rLtar <br />security piper witli',engrayed`border displaying the:Coloiado::stat <br />and signature of ttie;Registeaes PENALTY BY. AW Seetiotr 2sr-, <br />:._Colorado Revised Statutes; i9$2, if a perstiixfafters,:�ues�;;attem <br />e:orfurnishes to another for deceptive use vital'stetistiiis r <br />IF PIP. 1). 0 OPIEI?;.;.;.,.,. <br />I F1 PRJMBER ;.1,05 p20Qg45f4 <br />DATE OF::(ATH: <br />:.` OECEMt ER '*G, 20 <br />'DATE OF BIRTH (Mn1L)ev/Yr) '? <br />NOVEMBER 1,1970 <br />INSIDE CITY <br />bECEDENVE•EDUCA`t( <br />BACHELOR'S DEGREE <br />;<WAS CORONER NOTIFIED <br />YES .. . <br />COUNTY, STATE <br />>aA'S COLORAt» : <br />iME OF INJt <br />TIME PRONOUNCED DEAD':: <br />F+NDINGS:GONSIDEREO IN DEtE[' ININD <br />DATE SIGNED <br />ees/mER`1.7 2 <br />A. tXLEX'U tNTANA <br />STATE REGISTRAR <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE.' <br />