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<br />COLORADODEPA.. RT~...E..NT.O.....F.p....uallCH.'..E... AL.TH.......... AN......D......:. NVIRONM~A...O.. 8.....0 dS1 0
<br />HOLD TO L1GHTTO VIEWWATEIlIVIARt< .... .<: U 0
<br />STATIO OF (:OLOAAoo
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<br />Amended 811 A
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<br />1. oeceOENrS NAMIi (Fit!t. ifhM,.. Lull
<br />Maxine Mae ZAKAREc:KIS
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<br />u.s. ARMEOFORCES7
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<br />ZIP: 80910
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<br />26. r:.'~UH(~r~~ ~~.~.i~7:~~ OC\XUTe .1 In.. "
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<br />March 24. 2008
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<br />30. ~~M .TITl.E ~ONAILlNO'" ~"S ro E;RTIFI&,fI ~Q"" A(. :,' ".~r) "::' ','" """'" ,,' :'::..
<br />Robert C..Bux, MD (broner, ... ....p43 E. L~sVegas,Cplorado ~prings, Colorado
<br />:n.' ,NAME OF, ATTENOi~G 'PHYStC~~ IF"Olt1EFt T~"..CERTI.f:'ER (TY~"
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<br />ZIP, 80906
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<br />, MANNEIlOF OEA.....
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<br />o Suicide
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<br />34.1"M~O"'TE(:"USE IENJEA Ol\'lrONf lli\U$f i>EAUNfPOllIol./IoJ, ANlllcJ.l ~""~....oI~ ~*eo.,jlo..'~"" .......1.......
<br />PA~T ,01 End-stage chronic obstructivepulliionaiy disease ...
<br />CONOITIONS T.. .. ON 0
<br />IF ANy WH_Ct1
<br />:~~~::~ETg..I.ISE I~
<br />sr",nNG THE
<br />'U",OfAL Yl"'ll CAUSE
<br />LAST "', 'al
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<br />APR.. 0:32008 .
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<br />RONALDS. HYMAN
<br />STATE REGISTRAR
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<br />DATE ISSUED .. .' ....... i . ..... ....> .'. . . .........
<br />THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS
<br />RECORDED TN THIS OFFICE. Do not accept unless prepared on ... ..__......
<br />
<br />security paper with. engraved borderdispIayiJ1g the ColOTlWo state seal ............. '.1'1' .1111...1....11.11.1.11.111.....11.1111111111.111..11.1111.1....111.11...11111111
<br />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 rumisnes to another for deceptive use any vital stati~tics record. S L 3 8 6 7 0 4 3
<br />NUI- VALID IF..PHOTOCOP~?.....:..._~__,_~LL_-";,L______~--"~_i-,4__.i~_~i.___~~__~_~!'Y.:...2..~!9.:__,_,
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