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L71
<br />STATE OF COLORADO
<br />STATE OF COLORADO STATE FILE NUMBER
<br />200500234 CERTIFICATE OF DEATH
<br />1. DECEDENT'S NAME (First. Middle. Last) 2. SEX 3. DATE OF DEATH (Month, Day, Year)
<br />Ronald Lee MOORE ale April 07, 2003
<br />4. SOCIAL SECURITY 5a. AGE -Last. 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH 7. BIRTHPLACE (City and State or Foreign
<br />NUMBER Birth de (Years) os gyg His .Mini (Month, Da Year) Country)
<br />507 -36 -2817 76 June 2 , 1932 Grand Island, NE
<br />8. WAS DECEDENT EVER IN 9a. PLACEOF DEATH (Check onlyone)
<br />U.S. ARMED FORCES?
<br />Wes 0 No HOSPITAL: r OTHER
<br />Arpatient O ER /Outpatient 0 DOA ' 0 Nursing Home O Residence OOther(Specity)
<br />9b. FACILITY NAME pt not institution, give street and number) 1 9c. CITY, TOWN, OR LOCATION OF DEATH 9d. COUNTY OF DEATH
<br />University of Colorado Hospital Denver Denver
<br />10a. DECEDENTS USUAL OCCUPATION 10b. KIND OF BUSINESS /INDUSTRY 11. MARITAL STATUS - Married, 112. SPOUSE (It wile, give maiden name)
<br />(Give fond of work done during most of working life. Never Married, Widowed
<br />Do not use retired.) Divorced (Specify)
<br />Chairman of Board �; Via_ �;��
<br />Married Carol Lee Miller
<br />13a. RESIDENCE -STATE 13b. COUNTY TOWN,RLO 10 "x 13d. STREET AND NUMBER
<br />Colorado Arapahoe` 22 Cherry Hills Park Drive
<br />13e. INSIDE 13f. ZIPCODE a ASeE SPAIJI-0131RgI d 5. A an Indian, 18. DECEDENT'S EDUCATION(Specity oniyhighest
<br />CITY (W3pec fy No as - It ye`s, lty Cuban. �' °7 hi tc. (Specify) grade comp /efe0) Elementary or secontlary
<br />LIMITS? rfr% an, Ertl 'to etc h a (0 through f2) College (13 through 16 or 17 +)
<br />$boa 80110 mav� 16
<br />17. FATHER -NAME (First, Middle, L/(sf) 7& six, t s Elide6. IN RMANT -NAME and relationship to tleceesad.
<br />Ral h Moore ' Carol. Lee Moore, Wife
<br />20a. METHOD OF DISPOSITION Ob, PLACE ' O Dl P S TIOfl (Name of semetgry. 8re or 120c. LOCATION - City of Town, State
<br />s • a 0 Burial l}kCrematioo ❑ RernWahTrom State
<br />O Donation 0 Other (Spec fy) 'h i
<br />Purl Str�e rematoty _ Denver, Colorado
<br />21a. SIGNAT OF FUNERAL IREC1'OR OR 1ER9ON NG NAMEJ�F Aj'1DAE OF FACILI
<br />I>��s' GMn r chfdiocese o � Denver Mortuary
<br />.' 1 �0�, 44t vO , Wheat Ridge, f.0 80033
<br />22a. ROGI 3 R'3 IGNATURE n �;d 2be ATE FILED 01thlsy,
<br />MR'
<br />of 23. TIM F DEATH 24 NC " WAS CORONER NOTIFIED?
<br />Month `. ,Day''`°h c Ybar' (Yes or No)
<br />1110 M A rim 07 �` 1115 Yes
<br />TO BE COMPLETED< LY BY "T-IN 7P1q AN_ ... -^"' ,r'' TO BE COMPLETED BY CORONER
<br />26. To the best of myk owledge, death occurred abet 4s, dates pl,gs'er�nd dusr4e basis of ezaminatlon and/ orinvestigation ,In my op in ion tleath occurred at the
<br />the cause(sl and m�er es stated. ,,✓✓��� 1, ^'T 'a, die and place, and due to the cause(s) and menneyes stated.
<br />Signature /AJ����f9 �y " Signature �
<br />pe-
<br />1 28. DATE SIGNED (Month, Day, Year) -- '" 29. DATE SIGNED (Month, Day, Year)
<br />2 April 07, 2003
<br />30. NAME, TITLE AND MAILING ADDRESS OF CERTIFIER/CORONER(Type/Print)
<br />3 Dr. William A. Robinson 4200 East 9th Avenue, Denver, Colorado ZIP: 80262
<br />31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type /Print)
<br />4 32. MANNER OF DEATH 33s. DATE OF INJURY 33D. TIME OF 33e. INJURY AT 33d. DESCRIBE NOW INJURY OCCURRED
<br />(Month, Dry. Year) INJURY WORK?....
<br />Il Natural O Pend Investigation O Yas ONO
<br />5 Investigatlon M
<br />• Accident
<br />• Suicide 0 Undetermined
<br />Manner 336. PLACE OF INJURY -At h e, hrm, iraet, ladory. office 331. LOCATION (street and NumMr or Rural Route Number, Oty, County. State)
<br />• Homicide building, *to. (Specify) -
<br />34. IMMEDIATE CAUSE LEY R ONLYONE.CAUSE PER LINE FOR (al. (b), AND (c);) Do not enter mode ofdying (e.g. Cardiac or Respiratory Avest)slon i. Interval between onset
<br />PART and th
<br />al
<br />CONDITIONS DUE TO OR AS A CONSEOUE E -OF Interval between onset
<br />IF ANYWHICH / anQjaath
<br />GAVE RISETO (b)
<br />IMMEDIATE CAUSE DUE TO OR AS ACONS UENCE F Interval between onset
<br />STATING THE
<br />UNDERLYING CAUSE / /n/ .� /^ �y/ _ �/ ancLEeet�h
<br />LAST (c) (c) , _/ L' C.�i / �Y/ / rw-. �•,� a, jCf �f��'!< .
<br />PART OTHER SIGNIFICANT CONDITIONS- Conditions contributing todeath but not aced to cause in 135. AUTOPSY 38. IF YES unto findings considered
<br />11 PART I (en,., alcohol abuse, obesity, smoker). (yea or Ne) In determining cause of death
<br />No
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL CORD WHICH IS IN MY CUSTODY.
<br />16= 355379
<br />ADRS -16 1- a9(Rev.1.91) �.
<br />DATE ISSUED
<br />APR p LOCAL REGISTRAR
<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 />Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use
<br />any vital statistics record. NOT VALID IFPHOTOCOPIED.
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