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STATE OF COLORADO
<br />CERTIFICATE OF DEATH
<br />132 -595
<br />I. ULCLULN IS NAME IFhM, hildd`. Last)
<br />Clyde Edward BALLAIN
<br />SOCIAL SECURITY 59 . AGE i LAW( 5b. UNDER I YEAR Sr- UNDER t DAY
<br />NUMBER BMhdaY (ye•rl) Yt I Hta
<br />481 -05 -7304 83
<br />AS DECEDENT EVER IN B• PLACE OF DEATH (Chad bruyona)
<br />US ARMEDFORCES?
<br />xl Yet IT No HOSPITAL T OTH
<br />INnpal-f O ER/Outwtient O DOA n N
<br />SO . FACILITY NAME 111 nOt 115(dulrOn, PHI Wheat and number) ti4 CITY,
<br />Poudre Valle Hospital
<br />TOO OLCEUENTSUSVALOCCUPAT ION If)D. KIND FBUSINE59 /INDUSTRY
<br />IG- Amd of -rA dMe dump mOtf W wgArM Ills.
<br />200501419
<br />STATE FILE NUMBER
<br />2. 9LA 3 DAZE OF DEATH (MOnIlk Day, Year
<br />Male November 25, 1991
<br />amp None n Retldenm ❑ Other Is 00
<br />TOWN. OR LOCATION OF DEATH 90. COUNTY OF DEATH
<br />Fort Collins Larimer
<br />11. MARITAL STATUS - Ma-e4 12- SPOUSE (11 wdo. UNe maman n
<br />CITY ap1Y No w Te• It Yee •Pally Cub•rl B1ACI� Whll•. MC. ISpaGr,7 prada comp`;ami Ewmentary M setbndary
<br />LIMITS? s+rtan, PueriO Rltan, e1GJ IO MM"h 171 Corps 1131hrouph ISM 17 +)
<br />Yea No O Yee
<br />IMI 68801 MY White 12 years
<br />I t. FATHER NAM if, rWI, MwdN, La M) 14 H , L MWdla LeatlAls'dan Namal) RMANT NAM •np nWhbneMp lO d—ae4
<br />Ira Ballain Ella Schick Helen Balla/�i'�.n. - Wife
<br />700. METHOD OF DISPOSITION 20b. PLACE OF DISPOSITION 1Narlle of perrlarK —I-y, Or 20C- LOCATION -CatiMlOu,Stals
<br />❑ Bun•1 ❑ Gremalbn KR—I trbo Stole at.. M—)
<br />❑OOn•IIOn OOMer ISpwIN
<br />TA f-1 wn Memorial Park Grand Island Nebraska
<br />21► SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 214 NAME AND ADDRESS OF FACILITY:
<br />-1�1 alt'
<br />Allnutt - Goodrich Chapel
<br />301 East Olive
<br />!!JJ Fort Col ins Colorado zip: 80524
<br />A REGI S G TURE 221, DATE FILED 1411111 DaA 11,11
<br />November 26, 1991
<br />-- FDEATH 2e -DAP PRONOUNCED DEAD 1 25. WASCORONER NOTIFIED?
<br />Month Day I,-, Mm,' lyeW p Mq
<br />P M November 25 1991 10:I01` No
<br />TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN TO BE COMPLETED BY CORONER
<br />26 TO the Deal of mY Snbwtadpe, 0e•t ad el the e, data •nd pace. and due 10 21. On the bas's Ol e+Am-nat nan- -40,961a m nY Ophlbn death OCOUned at the
<br />the C: W.I erW manner A. M Dme, OAIe and pl.-. and Out to the uuNIM •M mM+Mr as stated.
<br />SpnMUn, /��l,Ae Srpnal-
<br />2S. DATE SIGNED IMOnm, Day. Vas,) 2B. DATE SIGNED (MOnth. Day. Year)
<br />2— November 26, 1991
<br />30 . NAME, TITLE AND MAILINGADDRESS F ERTIFIER OR N R17matpont)
<br />3— Dr. Mark Paulsen 1221 East Elizabeth Suite 4,Fort Collins, Colorado zip 80524
<br />31. NAME Of ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER Uypa/Pnnq
<br />4_ rO NER Of DEATH 77a DAT E OF INJURY ]70. TIME OF 17C. INJURY AT 334 DESCRIBE HOWINJURY OCCURRED
<br />t-0 0Pend np at. Y -4 INJURY WORK7
<br />5 _ m.eAlpellon ,,1 O Yea ONO
<br />Cldenl
<br />RWa O UrWatermined ttanM, 33a- RACE OF INJURY•At home, IUnl `reel It10ry, ofl" 331. LOCATION (Street arW N~ Or Rural Rgtte Number, City, Couty, BPI.)
<br />mlcldt b ndih%.1. (Sp.00
<br />PART 34. IMMEDIATE CAUSE (ENT.E /R ONL,.YYOONNE CAUSE PER LINE FOR fal ft ANDTFJ.I DO 101 is"I. m.. .1,11n. (6,g. C.I,ft.Or A.W.101 NrMi)abna I ^terv•I Delween onset
<br />le) l�� // L L,�C %%��l/✓i� ,iv% �.!%l�/ �1�' r�� and death
<br />I J
<br />CONDITIONS DUE TOURASA ONSEOUENCE OF Inlervei between -.1
<br />IF ANY WHICH / ^ }� //J�/ � ']% / /n�f]�{ /,H1, en0 death
<br />GAVE RISTE C Ibl 14 � [�-� I / �/2 IOL 1 `7/ 't/ 5 Y�/ '." " " L-
<br />IM MEOIATE CAUSE
<br />STATING THE DUE IO GRAS A CONSEQUENCE Interval between Msel
<br />LINDE FLYING CAUSE and death
<br />LAST IC) ICI
<br />PART OTHER SIGNIFICANT CONDITIONS- Cond m -- hl,lbubnp l0 death but not related lO GUSe In 135, AUTOPSY I 75, IF YE S were lMUpa-",Idarad
<br />11 PART I Ie p- eltoh°I abuse, obealty. tmoi erE (Yea Or Nq In detannlrllnp cause of death?
<br />No
<br />STATE OF COL0RAD0 )
<br />COUNTY OF LARIMER )
<br />I hereby certify that this document is a true and cor e t cop of the record in
<br />my custody. Issued in FORT COLLINS this C `day of A.D., 1991.
<br />Be
<br />THIS COPY NOT VALID UNLESS L Registrar 1 4
<br />PREPARED ON GREEN BASKETWEAVE
<br />PAPER AND IMPRESSED WITH RAISED
<br />SEAL OF LARIMER COUNTY REGISTRAR '
<br />OF VITAL STATISTICS. e ty Registrar
<br />PENALTY BY LAW if any person alters, uses, attempts to use or furnishes to
<br />another for deceptive use any vital statistics certificate.
<br />
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