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<br /> <br />200705522 <br /> <br />~ <br /> <br />1\.1.1.. <br />, 1 <br />)! ,: ~ <br />~ <br />I <br />I. <br />I <br />~' <br /> <br />2_ <br />3 <br /> <br />30. NAME, TITLE AND MAILING ADDRESS F CER , , R <br /> <br />Elizabeth Yoder ,MD. . <br />31. NA.ME OF ATTENOINO PHySICIAN IF OTHe HAN Rfl,FJ R (Ty~wPrim),: <br /> <br />80524 <br /> <br /> <br />-"C:~i.t;?J'-- <br /> <br /> <br />4 <br /> <br />a:a-. MANNER OF DEA.TH <br /> <br />3:;1(1, :,OESC".IPE HO~ ,1""t1IJRY' OCCURREO <br /> <br />)fJ N~hni.ll <br />OA,i;:cldet\.t <br /> <br />nPelldlniJ <br />h'lvl!t$li~"Il!)1'l <br /> <br />o Vea::::.c.:l.'No <br /> <br />5_ <br /> <br />[] Suicide <br />o HCl'ni(;ldli! <br /> <br />o Undcllht:rmi....,~d <br />Mar'll'l/;!'r <br /> <br /> <br />I~terval between onset <br />.nd....deat~, J <br />-, /2 u"" <br />Irihll'\1l!Jl ~tween onset <br />l;l:ild"death/ <br /> <br />PART 34, IMM.eOIAW ,t;AlJse t~~iEFf Olllt. YON.E CAIJS~':rER LI~~ 'FO;ftaJ..{b);)ND ~J,J Po"ot IIiIrIt-' moCh, ~:dvlng :(e.o. ~ or R88Dlmtory ~).Ion., <br />I <br />- -c6liiI51tION. <br />IF ANY WHICH <br />?~~7:;:~~E1gAUSF (bJ ,.' .,'. .. <br />STATING THE DUE; TO QR/,S A CON~~OllE::~E 0 <br />{,lNOe.AL'IING CAUSE <br />L.AST (el (C) <br /> <br />I:,,,.'.... <br /> <br />,. I <br /> <br /> <br /> <br /> <br />II.~: <br />." , . <br />'.1:-.'" I <br />.. <br /> <br /> <br />~ <br />~.I <br />J. ~ <br />ie' \ <br /> <br /> <br />Inb!lfV...1 bet-.eAIl onset <br />IInd death <br /> <br /> <br /> <br />DATE ISSUED <br /> <br />NOV 2 92006 <br />/ <br /> <br />...~s~ <br />. RONALD S_ HYMAN <br />STATE REGISTRAR <br /> <br />THTSTS A TRUE CERTIFICATION OF NAME AND FACTS As <br />RECORDED IN THIS OFFiCE. Do not accept unless prepared on <br />security paper with engraved border displaying the coIora~lo state seal <br />and signature of the Registrar_ PENALTY BY LAw, Section 25-2-118, <br />Colorado Revised Statutes, 1982,if a pei"sonalters, uses,tlttempts to <br />use or furnishes to another for deceptive use any vital statistics record, <br />NOT VALlD IF PHOTOCOPIED, <br /> <br />! IIlf 1111111111 ~ 1111111111111 11111 1111111111 ~~IIIIII <br /> <br />o 0 3 365 1 7 5 <br />