Lynn Ivan dDimmick31�
STATE QF COLQR Vi4x'
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STATE OF COLORADO STATE FILE NUMBER
CFRTIFICATE'OF DEATH `=
AMENDED 2261A
_ 2. SEX 3. DATE OF DEATH (Month, Day, Year)
1, DECEDENT'S NAME (First, Middle Last)
Ivan DIMMICI�.. M August 30, 2003
Lynn 7. BIRTHPLACE (City and State or Foreign
4. SOCIALSECURITY 5a. AGE Last. 5b, UNDER 1 YFAR Sp.. UNDERI DAY. 5 Q Od7hODally Yoar) Coynfry)
NUMBER Birihday(Years) os "; ays, yrs td. s , . 1�13y '1, -53.7 Omaha, NE ..
507-05-7079 86
,r S. WAS DECEDENT EVER IN 9a, PLACE OF DEATH(Chec-rdy one)
U.S. ARMED FORCES? HOSPITAL: " OTHEfl_
❑Yes LxNo; ❑Inpatie+tl:' ❑ER/Outpatient DDOA tl Nursing Home U Residence )o Other(specily) IIOS 1Ce
96, FACILITY NAME Of not lnsiflubon, give street and number) 9c. lY T WN OR: LOCATION OF DFATH 9d. COUNTY OF DEATH
Pikes Peak Hos ice Colorado Springs El Paso
loa. DECEDEN TSUSUAL OCCUPATION lob. KIND OF BUSINESS/INDUSTRY - .11. MARITALSTATUS-Married, 12. SPOUSE (it wile, give maiden name)
IOtve Mndol workdongdudng most of working tile. _ NeYar Marded Wklmed,
17o not use Fall, zndllS'trial b,Wbrced (specify)
Maintenance Man Mariiifacturng - Widowed _ Teddi Allen
13a. RESIDENCE -STATE 136. COUNTY ' 'ic. CrISY ;tOWN OR LOC{)T QN v� 13d STREET AND NUMBER t
Colorado El Paso `Colorado springs' 7252 SiouxCircleN.
13e:. CITY E 131. ZIP CODE DENT'S ED I
1� WAS DECEDENT OF HISPANI GRlGiN7 15 81dC�Ythila g�c(3pedly) 1S:�EdeEo 120feN lament of selcondery hest
.: (5pedtY;No opYes - Ityes, speNl Cub$n ai r . (o Ihmug6 121 Co4ege (13 through 16 or 17+)
LIMITS? " Mexican; Puedo Rican, eta} ,t
Li 74 No 'D Yes White 8
gLNo 809'15
17. FATHER -NAME (Fjrst,;Mid tlfe Lasq to MOTHER NAME {FFrsF M(ddle, st(Mai�en Na.ma)3 19;;INFORMANRNA E and relationship to deceased.
Douglas Dmmick Ruby larberr T ;Lee Dimmick" Son
2oa. METHOD OF DISPOSITION - - 20b. PLACE OF DISPOSITION Ohoe. of ceme(ery, oree1ato(y, of. 29C. LOCATION • City orTown, State
Olhef place)
F ❑Budel ¢tCrematlon,.DRemovat(romS)pte COlor�da SpringS=Mbrtuary & :.
Colorado Springs, CO
D oonatlon D Qmey(Spetiiyi . , (;refiatlor} , SerYices . , . .:
21.91GNATUREOFFUNERAL DIRECTORORPERSON,.ACTINOASSUCH 21R NAMEANb ADDA, OKFACILITY;
Chi orac#o S tinge Mortuary & Cremation Services
Sue Hutton 34
6W
Astro�Zon
ging-, or
zle: 80910
Coloradt� 8 rings,.
22a. REGISTRAR'S SIGNATURE - 22b. t)ATEFILED(Monih, Day, Year) -
23. E FD ATE NOU CED D,,-
24. 25'WAS CORONER NOTIFIF ?
Year Novi
7:05 A> 1d August 3.0
ay 20 3 7. =05 AM".
To -B :COMPLETED ONLY BYCERTIF'YING PHYSICIAN <, TO RE COMPLETED BY CORONER
28. To the best of my kn0 edge, death Occurred at the time date and pace enddueto 270nlhebas+s of examinatlon and/orinvesligaooO,inmyopiniondeathoccurredalthe
the causes) and man r as slated. �j A - time, date and place, and due to the cause(s) and manner as slated.
SfgnalUre,
28. bA7ESIGNEO o -h, Day, Yoar) "i 20DATESIGNED{Month, Day, Year)
2,P
03
z
-30. NAME,TITLEA DIAl CINGADDRESS OF CERTIFIER/CO O)yER (ry(Se/Prinp : 80903
3 Jonathan -Pr' Weston, MD,. 825..E. Pikes Peak, Colorado Sprangsy:C0 ZIP:
31, NAME OF ATTENDING PHYSICIAN IF OTHEH THAN CERTIFIER (Ty➢e�PdnQ
4 32. MANNEROFDEATH 33s. DATEOPINJURY 33b}TIME�F 330 INJURV AT 3 d, DESCRIBE HOWINJURYOCCURRED
(Month,DaYYesq .:INJURY WORf(?. - _
� N.t.ml 0 Pending D Yes ONO
5 - investigation fd
D Accident : -
❑Suitide [IUndetermined 331 LbCAT(QN(Stceetarld Nurimtiercr Rural ROule Number, City, County. State)
Manner_. 33e.PLACEQF INJURY AIhdne,fatm,drse4fadoryPtfice_
building, etc, l$paoffy)
D Homicide (.
34. IMMEDIATE CAUSE (ENTER ONLYONE CAUSE PER LINE FOR fal (ti), AND (cA) Do not enter mode of dying (e.g. Cardiac or Reaplralbry ArrssUalone. Interval br:hveon onset
and
a1h
a PART (a)Metastatic transitional cell car(11noma of the bladder un%nown
s CONDITIONS ` 'OUETO OR AS A CONSEQU6NC OF : - _ Interval between onset
` .. :: `_ anddealh
IF ANY WHICH
GAVE RISETO(b) -
IMMEDIATE CAUSE Interval between onset
STATINGTHE' DUE TO OR AS A CONSEOUENCE OF - end death
UNDERLYING CAUSELAST ici
- -
35. AUTOPSY 36. IF YES were findings cOntldared -
PART OTHER SIGNIFICANT CONDITIONS- Condi9onscpnlributinglddeatt bulnotrelaled to cause In 4 (Yes or No) indelerminlnq cause of death?
It PART I (e.g_ alcohol abuse, obesity, smoker). ' - "
NO
THIS 1S TO CERTIFY THAT THIS IS A TRUE AND CORRECT DOPY OF THE OFFICIAL RECORD WHICH 1S IN MY CUSTODY.
57
n N
!4�F DATE ISSUED V 2003 RONALD S H�AN
3r 011STATE REGISTRAR t
F
signature of theRe'strar,. PENALTY BY LAW, $cction ,25 - 18;Colorado Revised
fr j Do. not accept unless prepared on security paper with engraved border displaying the Colorado state
seal and g
Statutes, 1982, if any person alters, uses; attempts to use furnishes to another for deceptive use }
fl any vital statistics record NOT VALID IF PHOTOCOPIED.REv o7/03
:.
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