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HomeMy WebLinkAbout03.0 Mineral Owners of Record StatementMINERAL OWNERS OF RECORD STATEMENT FOR: CHANGE OF USE/LIMITED IMPACT REVIEW 28730 6 & 24 HWY, Rifle, CO LOCATED IN GARFIELD COUNTY August 4, 2017 PREPARED FOR: BJ Services LLC 28730 6 & 24 HWY Rifle, Colorado PREPARED BY: RIVER CITY CONSULTANTS 744 HORIZON CT., SUITE 110 GRAND JUNCTION, CO 81506 The Mineral Owner of Record is Ardis A. Green. She owned the mineral rights in joint tenancy with George D. Green until has passing in 2002. Mrs. Green's address is 602 County Road 221, Rifle, CO 81650. Following this page is supporting documentation from the public records search completed on August 4, 2017. RIVER CITY CONSULTANTS, INC. ■ 744 HORIZON COURT SUITE 110 ■ GRAND JUNCTION, COLORADO 81506 ■ 970.241.4722 Return to Search Results You searched for: RecDatelD >= Wed Feb 21 00:00:00 MST 1883 and <= Fri Aug 04 00:00:00 MDT 2017 and exact search in GrantorlD for Green George 124 items found, displaying 101 to 124.[First/Prev] 1, 2 [Next/Last] Description Summary Financing Statement (UCC7) 436543 07/07/1992 01:34:00 AM B: 836 P: 81 Grantor: GREEN, GEORGE Grantee: COMMODITY CREDIT CORP Financing Statement (UCC7) 443119 01/12/1993 09:12:00 AM B: 852 P: 196 Grantor: GREEN, GEORGE, GREEN, ARDIS Grantee: COMMODITY CREDIT CORP Warranty Deed Rec Date: 12/06/1993 04:32:00 PM BookPage: B: 884 P: 893 Related: 456148 Grantor: GREEN, GEORGE D, GREEN, ARDIS A Notes: Grantee: REGULSKI, ROBERT, RIFLE SKI CORP Legal: Section: 11 Township: 6S Range: 93W Plat Rec Date: 12/07/1993 03:18:00 PM BookPage: P: 0 Related: 456223 Grantor: GREEN EXP PLAT, GREEN, GEORGE, GREEN, ARDIS Notes: DRAWER 1A FICHE 125 Grantee: GREEN EXP PLAT Legal: Section: 11 Township: 6S Range: 93W Settlement Agreement 460735 Rec Date: 03/21/1994 02:46:00 PM BookPage: B: Grantor: GREEN, GEORGE D, GREEN, ARDIS, GIULIANI, AUGUST, ... Notes: 896 P: 324 Related: Grantee: GREEN, GEORGE D, GREEN, ARDIS, GIULIANI, AUGUST, ... Legal: Subdivision: 91133 FIRST NATL BANK ADD LOT 6 BLK 2 Warranty Deed 463770 Rec Date: 05/26/1994 04:20:00 PM BookPage: B: 903 P: 789 Related: Grantor: GREEN, GEORGE D, GREEN, ARDIS A Notes: Grantee: CLOW, TRISHA J Legal: Subdivision: 91133 FIRST NATL BANK ADD LOT 6 BLK 2 Oil And Gas Lease 469737 Rec Date: 10/18/1994 11:10:00 AM BookPage: B: 919 P: 215 Related: Grantor: GREEN, GEORGE D, GREEN, ARDIS A Grantee: BARRETT RESOURCES CORP Notes: Legal: Section: 1 Township: 4S Range: 94W Partial Rel Of Deed Of Trust 478796 Rec Date: 05/31/1995 03:34:00 PM BookPage: B: 942 P: 489 Related: Grantor: PUBLIC TRUSTEE-GARFIELD COUNTY, Grantee: REGULSKI, ROBERT, RIFLE SKI CORP GREEN, GEORGE D, GREEN, ARDIS A Notes: Legal: Section: 11 Township: 6S Range: 93W SEE DOCUMENT Financing Statement (UCC7) 483264 09/19/1995 04:01:00 PM B: 953 P: 437 Grantor: GREEN, GEORGE, GREEN, ARDIS Grantee: GARFIELD COUNTY FSA OFFICE, COMMODITY CREDIT CORP Description Summary Oil And Gas Lease 483788 Rec Date: 10/02/1995 03:42:00 PM BookPage: B: 954 P: 634 Related: Grantor: GREEN, GEORGE K -AKA, GREEN, Grantee: BARRETT RESOURCES CORP GEORGE, GREEN, ARDIS A -AKA, ... Notes: Legal: Section: 1 Township: 6S Range: 93W SEE DOCUMENT Partial Rel Of Rec Date: 04/23/1996 03:35:00 PM BookPage: B: 975 P: 70 Related: Deed Of Trust Grantor: PUBLIC TRUSTEE-GARFIELD COUNTY, Grantee: REGULSKI, ROBERT, RIFLE SKI CORP 491957 GREEN, GEORGE D, GREEN, ARDIS A Notes: Legal: Section: 11 Township: 6S Range: 93W SEE DOCUMENT Quit Claim Deed Rec Date: 03/19/1998 04:18:00 PM BookPage: B: 1058 P: 528 Related: 522081 Grantor: GREEN, GEORGE D, GREEN, ARDIS A Grantee: GREEN, GEORGE D, GREEN, ARDIS A, GREEN, DARRELL C Notes: Legal: Section: 1 Township: 6S Range: 93W SEE DOCUMENT Notice Of Lis Pendens 528167 Rec Date: 07/06/1998 03:42:00 PM BookPage: B: Grantor: MOYER, CARMEN L, SPANGLER, KENNETH G, SPANGLER, MARY L, ... Notes: 98CV167 1076 P: 499 Related: Grantee: COTTONWOOD SPRINGS LLC Legal: Section: 10 Township: 6S Range: 93W SEE DOCUMENT Quit Claim Deed Rec Date: 08/04/1998 04:29:00 PM BookPage: B: 529926 Grantor: GREEN, GEORGE D, GREEN, ARDIS A Notes: 1081 P: 889 Related: Grantee: COTTONWOOD SPRINGS LLC Partial Rel Of Deed Of Trust 544466 Rec Date: 04/26/1999 10:40:00 AM BookPage: B: Grantor: PUBLIC TRUSTEE-GARFIELD COUNTY GREEN, GEORGE D, GREEN, ARDIS A Notes: Legal: Section: 10 Township: 6S Range: 93W SEE DOCUMENT 1126 P: 227 Related: 456149 Grantee: REGULSKI, ROBERT, RIFLE SKI CORP Legal: Section: 11 Township: 6S Range: 93W SEE DOCUMENT Release Of Deed Rec Date: 04/30/1999 10:06:00 AM BookPage: B: 1127 P: 179 Related: 478742 Of Trust 544731 Grantor: PUBLIC TRUSTEE-GARFIELD COUNTY, Grantee: DUBOIS, WILLIAM H SR, DUBOIS, GREEN, GEORGE D, GREEN, ARDIS A, ... DONNA M Notes: Legal: Correspondence Rec Date: 01/10/2000 01:46:00 PM BookPage: B: 1168 P: 440 Related: 557808 Grantor: GREEN, GEORGE D-ETAL, REDMOND, JIM-ETAL, MCCLUNG, RILEY W-ETAL, ... Notes: Grantee: GREEN, GEORGE D-ETAL, REDMOND, JIM-ETAL, MCCLUNG, RILEY W-ETAL, ... Legal: Section: 1 Township: 6S Range: 93W SEE DOCUMENT Warranty Deed 561130 Rec Date: 03/27/2000 12:45:00 PM BookPage: B: 1178 P: 453 Related: Grantor: GREEN, GEORGE D, GREEN, ARDIS A Notes: Grantee: LUGINBUHL, PAUL B, LUGINBUHL, JIM E Legal: Section: 11 Township: 6S Range: 93W SEE DOCUMENT Description Summary Warranty Deed Rec Date: 11/16/2000 12:06:00 PM BookPage: B: 1217 P: 699 Related: 572303 Grantor: GREEN, GEORGE D, GREEN, ARDIS A Grantee: BIG MOUNTAIN RANCH LLC Notes: Legal: Section: 1 Township: 4S Range: 94W SEE DOCUMENT Warranty Deed 572305 Rec Date: 11/16/2000 12:13:00 PM BookPage: B: 1217 P: 702 Related: Grantor: GREEN, GEORGE D, GREEN, ARDIS A Grantee: BIG MOUNTAIN RANCH LLC Notes: Legal: Section: 1 Township: 4S Range: 94W SEE DOCUMENT Oil And Gas Lease 577739 Rec Date: 03/19/2001 02:38:00 PM BookPage: B: 1238 P: 428 Related: Grantor: GREEN, GEORGE D, GREEN, ARDIS A, Grantee: BARRETT RESOURCES CORP GREEN, DARRELL C Notes: Legal: Section: 1 Township: 6S Range: 93W SEE DOCUMENT Oil And Gas Rec Date: 03/19/2001 02:41:00 PM BookPage: B: 1238 P: 434 Related: Lease Grantor: GREEN, GEORGE D, GREEN, ARDIS A Grantee: BARRETT RESOURCES CORP 577741 Notes: Legal: Section: 2 Township: 6S Range: 93W SEE DOCUMENT Partial Rel Of Deed Of Trust 595658 Rec Date: 01/15/2002 12:09:00 PM BookPage: B: 1320 P: 670 Related: 456149 Grantor: PUBLIC TRUSTEE-GARFIELD COUNTY, Grantee: REGULSKI, ROBERT, RIFLE SKI CORP GREEN, GEORGE D, GREEN, ARDIS A Notes: Legal: Subdivision: 485657 GREENE SUBDIVISION EXP Parcel: 1 Supplemental Rec Date: 12/10/2002 03:54:00 PM BookPage: B: 1415 P: 619 Related: 522081, 228394, 249849, ... Affidavit Grantor: GREEN, GEORGE D -DEC Grantee: GREEN, GEORGE D -DEC, GREEN, 616334 ARDIS A, GREEN, DARRELL C Notes: Legal: Subdivision: 37488 ANTLERS ORCHARD DEVELOP CO PLAT #1 Tr... 124 items found, displaying 101 to 124.[First/Prev] 1, 2 [Next/Last] Return to Search Results 111111111111 I111111111111111111111111111111111111111111 0\j 616334 12/10/2002 03.54P 81415 P619 M PLSDORF 1 of 5 R 26.00 D 0.00 GARFIELD COUNTY CO STATE OF COLORADO ) ) ss. COUNTY OF GARFIELD ) NICHOLAS W. GOLUBA, JR. ("Affiant' his oath, deposes and says: SUPPLEMENTARY AFFIDAVIT (Joint Tenancy) '), of lawful age, being first duly sworn upon AFFIANT has personal knowledge of the fact that GEORGE D. GREEN, who is named as the deceased in the attached certified copy of Certificate of Death, was at the time of his death the owner, in joint tenancy with ARDIS A. GREEN, 0603 County Road 221, Rifle, Colorado 81650 and DARRELL C. GREEN, 1009 County Road 223, Rifle, Colorado 81650, of all that real property described in Deed recorded in Book 1058 at Page 528 as Reception No. 522081 of the Garfield County, Colorado records, which property is more fully described as follows: A portion of Lot 4 and a portion of the SW 1/4 NW 1/4 of Section 1, Township 6 South, Range 93 West of the 6"' P.M., Garfield County, Colorado, also described as Tracts 9 and 24 on Plat 1 of the Antlers Orchard Development Company as Reception No. 37488 in the records of Garfield County, Colorado, said property being more correctly described as follows: Commencing at the west 1/4 corner of said Section 1, also being the southwest corner of Tract 25 as shown on Plat 1 of Antlers Orchard Development Company as Reception No. 37488 in the records of Garfield County, Colorado, also being the southwest corner of the S W 1/ SW 1/ NW 1/ of said Section 1; thence N022'15' W 660.04 feet along the west line of said Tract 25 and of said SW 1/ SW 1/ NW 1/4 to the TRUE POINT OF BEGINNING, also being the southwest corner of said Tract 24 and of the NW1/4SW1/4NW% of said Section 1; thence N0°21'31"W 1320.08 feet along the west line of said Section 1, also being the west line of said Tracts 9 and 24, to the northwest corner of said Tract 9; thence N89°53'08"E 659.84 feet along the north line of said Tract 9 to the northeast corner of said Tract 9; thence S0°23'08"E 1320.06 feet along the east line of said Tracts 9 and 24 to the southeast corner of said Tract 24 and of said NW%SW'/4NW1/4; thence N89°43' 16"E 659.84 feet to the TRUE POINT OF BEGINNING, also being the southwest corner of said Tract 24 and of said NW 1/ SW 1/4 NW 1/ TOGETHER WITH all improvements thereon, and together with all water and water rights, ditch and ditch rights, reservoirs and reservoir rights appurtenant to the above-described real property, including but not limited to all Silt Project water rights appurtenant to the above-described real property and 4.80 shares of the capital stock of the Farmers Irrigation Ditch Company. AND THAT AFFIANT has personal knowledge of the fact that GEORGE D. GREEN, who is named as the deceased in the attached certified copy of Certificate of Death, was the owner, in joint tenancy with ARDIS A. GREEN, 0603 County Road 221, Rifle, Colorado 81650, of all other real property located in Garfield County, Colorado in which said Decedent had an interest at the time of his death, including without limitation, the following lands and mineral interests, all located in Garfield County, Colorado, to -wit: LANDS (a) NE 1/4 NE 1/4 , Section 11, Township 6 South, Range 93 West of the 6"' P.M.; and 111111111111111111111111111111111111111111111111111111 616334 12/10/2002 03:54P 81415 P620 M ALSDORF 2 of 5 R 26.00 D 0.00 GARFIELD COUNTY CO MINERAL INTERESTS (b) All oil, gas and other minerals in and under the SE I/4 NE '/4 , Section 11, Township 6 South, Range 93 West of the 6th P.M. (Source: Deeds to George D. Green and Ardis A. Green as joint tenants, recorded in Book 363 at Page 189, Reception No. 228394 and in Book 419 at Page 312, Reception No. 249849, respectively. Mineral reservation in Deed to Kenneth Chambers, Patricia Chambers and Flint Chambers, recorded in Book 686 at Page 350, Reception No. 370097; and mineral reservation (no right of surface entry) in Deed to Robert Regulski and Rifle Ski Corporation, recorded in Book 884 at page 893, Reception No. 456148;) and (c) All oil, gas and mineral rights in and under the following described lands: A tract of land in West Half of the Southwest Quarter (W1/2SW1/4) of Section Eleven (11), Township Six (6) South, Range Ninety -Three (93) West of the Sixth (6"') P.M. lying North of the railroad right-of-way and of the state highway as the same are now surveyed, constructed and in place, and more particularly described as: Beginning at a point whence the Southeast Corner of Section Ten (10), Township Six (6) South, Range Ninety -Three (93) West of the Sixth (6th) P.M. bears South 00°10' W., 1320.0 feet; thence North 00°10' East, 596.33 feet to the county road; thence along the county road North 42°17'30" East, 119.28 feet; thence South 00°10' West, 684.80 feet; thence North 89°50' West, 80.00 feet to the point of beginning. (Source: Deed to George D. Green and Ardis A. Green as j oint tenants, recorded in Book 351 at Page 459, Reception No. 222172. Mineral reservation in deed to Walter S. Moyer and Carmen L. Moyer, recorded in Book 380 at Page 42, Reception No. 236314.) (d) An undivided one-half (1/z) interest in all minerals, including oil and gas, in and under the following described lands: A tract of land situated in the SW'% of Section 11, Township 6 South, Range 93 West of the 6th P.M., lying Southeasterly of the Southerly right-of-way line of a Garfield County road as constructed and in use, more fully described as follows: Beginning at a point whence the Northwest Corner of the SW%SW'/< of said Section 11 bears N.89°50' W. 80.00 feet; thence N. 00°10'E. 684.80 feet to a point on the Southerly right-of-way line of said road; thence N. 38°58'07" E. 239.38 feet along the Southerly right-of-way line of said road; thence S. 00°10' W. 871.35 feet; thence N. 89°50' W. 150.00 feet to the point of beginning, containing 2.68 acres, more or less. Also a tract of land situate in the SW'% of Section 11, Township 6 South, Range 93 West of the 6`s P.M. and more fully described as follows: Beginning at the Northwest Corner of the SW1/4SW'/ of said Section 11, Thence South 89°50' E. 100 feet, thence South 00°10' West 752.10 feet, more or less to the North line of Colorado State Highway 6&24 thence South 63°30'50" West 111.73 feet, more or C.1Office Data1CLIENT\Green\Eatete\12-10-02 Supp Affidavit.wpd 2 1 111111 11111 111111 111111 11111 1111 111111 111 1111111111111 616334 12/10/2002 03 54P 81416 P621 M ALSDORF 3 of S R 26.00 D 0.00 GARFIELD COUNTY CO less to the West line of said SW'44 SW % of Section 11, thence North along said line to the Northwest Corner of said SW%%SWY4 of Section 11, the point of beginning. (Source: Deed to George D. Green and Ardis A. Green as joint tenants, recorded in Book 351 at Page 459, Reception No. 222172. Mineral reservations in Deed to Walter S. Moyer and Carmen L. Moyer recorded in Book 416 at Page 129, Reception No. 248599 and in Correction Deed to the Moyers, recorded in Book 417 at Page 66, Reception No. 248933. (e) An undivided one-half (1/2) interest in all minerals, including oil and gas, in and under the following described lands: A tract of land situated in SW'/ of Section 11, Township 6 South, Range 93 West of the 6th P.M., lying Southeasterly of the Southerly right-of-way line of a Garfield County road as constructed and in use, and more fully described as follows: Beginning at a point whence the Northwest corner of the SW'/ SW'/4 of said Section 11 bears North 89°50' West 230.00 feet; thence North 00°10' East 871.35 feet to a point on the Southerly right-of-way line of said road; thence North 42°27' East 421.72 feet along the Southerly right-of-way line of said road; thence South 00°10' West 1427.79 feet to a point on the Northerly line of the property described in a deed recorded in Book 376 at Page 490 of the Garfield County records; thence South 63°30'50" West 462.93 feet along the said Northerly property line to the Northwest corner of the property described in the aforesaid deed; thence North 00°10' East 452.10 feet; thence South 89°50' East 130.00 feet to the point of beginning. (Source: Deed to George D. Green and Ardis A. Green as joint tenants, recorded in Book 351 at Page 459, Reception No. 222179. Mineral reservation in Deed to Robert A Crabtree and June Irene Crabtree recorded in Book 392 at Page 337, Reception No. 240249.) (f) An undivided one-half (1/) interest in all oil, gas, minerals and fissionable materials in and under the following described lands: That part of the W' SW'/ of Section 11, Township 6 South, Range 93 West of the 6th P.M. lying Northerly of the Railroad and Highway as constructed and in place, except those parts conveyed out by Document Nos. 214917, 234890, 236314, 240249 and 248599. (Source: Deed to George D. Green and Ardis A. Green as joint tenants, recorded in Book 351 at Page 459, as Reception No. 222179. Mineral reservations in Deed to Ted E. Mullennix and Stephen B. Price recorded in Book 443 at Page 290, Reception No. 257904 and in Correction Deed to Mullennix and Price, recorded in Book 455 at Page 588, Reception No. 261830). (g) All oil, gas and other minerals and mineral rights in and under the following described lands: Lot 1, Section 2, Township 6 South, Range 93 West of the 6t' P.M. (Source: Deed to George D. Green and Ardis A. Green as joint tenants, recorded in Book 419 at Page 312, Reception No. 249849. Mineral reservation in Deed recorded in Book 681, at Page 959, Reception No. 368044. C:1Otrice Data 1CLIENT \ Green \Estate\12-10-02 Supp Atridavit.wpd 3 1 111111 11111 111111 111111 11111 1111 111111 III 1111111111111 616334 12/10/2002 03:54P 61415 P622 M ALSDORF 4 of 5 R 28.00 D 0.00 GARFIELD COUNTY CO AND THAT AFFIANT has personal knowledge of the fact that GEORGE D. GREEN who is named as the deceased in the attached certified copy of Certificate of Death, was at the time of his death the owner and holder, in joint tenancy with ARDIS A. GREEN, 0603 County Road 221, Rifle, Colorado 81650, of the following described notes or evidence of debt: (a) Installment Promissory Note, dated December 1, 1993, in the original principal sum of $135,000, payable by Robert Regulski and Rifle Ski Corporation to George D. Green and Ardis A. Green, as joint tenants, secured by Deed of Trust recorded in Book 0884 at Page 895 as Reception No. 456149 of the Garfield County, Colorado records; and (b) Promissory Note dated March 27, 2000, in the original principal sum of $324,000, payable by Paul B. Luginbuhl and Jim E. Luginbuhl to George D. Green and Ardis A. Green, as joint tenants, secured by Deed of Trust recorded in Book 1178 at Page 455 as Reception No. 561131 of the Garfield County, Colorado records. AFFIANT has no record interest, nor any interest whatsoever in the above described real property, lands, mineral interests, promissory notes or in the real property se uring said notes AFFI icholas W. Goluba, Jr. Subscribed and sworn to before me this lOth day of December, 2002, biAir Goluba, Jr. -7f a 4 G Witness my hand and official seal. My commission expires: is - q-,200( C:\Office Data \ CLIENT \ Green \Estate112-10-02 Supp Affidavit.wpd 4 CERTIFICATION; QF VITAL RI 0 2 3� CR169835 THIS IS TO CERTIFY THAT THIS ISA TRUE AND CORRECT COPY OF THE OFFICIAL RECORD WHICH IS IN MY CUSTODY. STATE OF COLORADO STATE OF COLORADO CERTIFICATE OF DEATH STATE FILE NUMBER u1f,!•ii ,s•,1�3 1. DECEDENTS NAME (FIOSI MMdle, Lean George Duane GREEN 2. 8E8 Male 3 DATE OF DEATH (000011, Day, rear) November 5, 2002 NUMBER 'Mir' 524-34-8351 0o.AGE -Last Sb. UNDER IYEAR Sc. UNOE3 1DAV B. DATE 0F01RTH IMenln, Day, Year) July 18, 1923 T. BIRTHPLACE (CIO and 3fete sr Foreign Rifle, Colorado Birthday lYear) 79 Mos ;Dave Ho :Mina B WA3 02000ENT EVER IN U.9. ARMED FOR0(187 10 Yea 0 N 9a. PLACE OF DEATHIGnacx only ono HOSPITAL: 0 Inpatlenl ❑ER/Outpatient ❑DOA 1 ©Nu10109 Home ID Residence o OIhel(Spaci41 90. FACILITY NAME(0 not Mad 1130, plus Omar ono numbed At Home - 603 County Road 221 08 CITY, TOWN, OR LOCATION OF DEATH Rifle 0E. COUNTY OP DEATH Garfield 102. DECEDENTS USUAL OCCUPATION 6Give Midofweradone during meal werklnp Ills. psaaare"real Rancher 101,. KIND OF BUSINESS/INDUSTRY Agriculture 11. MARITAL STATUS . Moiled. NewDivorced Widowed, Married 12. SPOUSE (if 1100, gam maldan soma) Ardis A. Hoaglund 135 RE810ENCE-STATE Colorado 13, DO3NTY Garfield 13c. CITY, TOWN, OR LOCATION Rifle 13d. STREET AND NUMBER 603 County Road 221 13e. FM CITU LIMITS, oYee pJ Na 131. ZIP CODE 81650 14. WAD DECEDENT OF HISPANICORIOIN9 /1Sooaoo.Noo Zvi -Il ,really Cuban, M IU n, Puea.n, Ncl �:e,is n 1 E. RAG. American Indian, 000l4Whlle,,tc. (0300fyl White 10. DECEDENT'S EDUCATION I3pacf/vonrnlpnael co proledlElememaryoraecandary �lAravph 121 COItepe 119Mroupn 0)e 0)r 11+) 12th 17. FATHER -NAPA William IFIraLMIdd3.(3011 18 MOTHER -NAME (Fast, Middle, La r(Malden Hamall Duane Green Hazel Dehong 19, INFORMANT -NAME 1,331tlenehip to deceased. Mrs. Ardis Green - Wife ens. METHOD OF DIBP091T ION 200. PLLAC°MarEEI01DISPOSITION (Name of cemetery crematory, or 200. LOCATION -CIN or TOWS SOW ) 0 0011.1 X Cremation 0 Removal from Stat, ❑Donation 0Omer 13A0004 Grant Crematory Craig, Colorado 1 00 DAM -01 N 0800 ACTING AB SUCH �,✓ 214 NAME AND ADDRE9SOF FACILrTY: Meeker Mortuary - 517 Park Avenue P.O. Box 1048, Meeker, Colorado nP: 81641 210. PAYE FILED (Mon WF, riarl 23. TIMEIIF DEATH 220. D„TESIFLNOUNCED OOD Near 8. 2SW#BOLONRONER NOTIFIED? 8:27 a. M November 5, 2002 8:27 a.m. Yes TO 13P cow 0NLYEYCHATIFYINO PHYSICIAN TOSE COMPLETED EY CORONER 28To1habntolm hno a,tait el0o0cuna llnedme, dere and place, and due to one e.use(n sn�mann (.tad. Slvnebre, 2T. Onthebute 1200,Mellonand/or1a09100an0n, 11110 1000d0ethoccumd 000, nme,daee and Flee., and da. 0)F m. eau�..(ae/na m.lW.ra.,ten5 6lpnafpre► �� 20. DATE SIGNED Doth, pay, Year) November 6, 2002 . 20: PATE SIGNED (Month, Day, ,car) //p,J. Ca - o 30. NAME, TITLE Alp MAIL IRO ADDRESS OF CERTIFIER/CORONER ITol&Alol) William A. Kelley, M.D., 790 Wellington Ave. Suite 105, Grand Junction MP: CO 81501 31.. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTI IER (Tyae/Pri00 32. MANNER OF DEATH 10 Nalprel 0 3.028( .doE 0Acoldenl 08uiide Mgtl0M0'minad O NsmleiN 335 (00009,0 , INJURY U) 934 TIME OF INJURY M 33a WOR AT 0Yu ONo 330 DESCRIBE HOWINJUIW OCCURRED 33a. PLACE OF INJUma RY.v) hone, farm, 109.4, Moiety, 0004. buil 391. LOCATION 38110.1 Ned N Lifter aFN01 Route Number, CN. C0M1N• MOM 35 IMMEDIATE CAUSE (ENTER ON ONE CAUSE PER LINE FORM IN AND ND Oan4.4., 10,0014094115(04 C101.,01R IHRMry Arrie•O pie. PANT / ./-•r 1 iN SAi, 4 CLie-r.e.s CONDITIONS DUE TO ORASA CON9E UENGEO IF ANYY/HIT0 IMMEDI TEC (b) IMMEDIATE DUE TO OR AS A CONSEQUENCE OF UNDERSTATINTHE I, ST IS) IND CAUSE AST IS) IO !Marvel Masan once and eM daaA Intemi bseaaw onset and OmaM1 larvU beShrum ones an a death PART 0!IIFICANTCONDTI0Y6- Conditions contributing to dein, but not misted bemuse In 11 PART100, C./.2A(1uc 6041k'K 38. AUTOPSY 113.0,50) No 313. gs M datelminIn801u0 &M.H DATE ISSUED Sri -cv Do not accept unless prepared on security paper with engraved border displaying the Colorado state seal and signature of the Registrar. PENALTY BY LAW, Section 25-2-118, Colorado Revised Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use any vital statistics record. NOT VALID IF PHOTOCOPIED, VR iooCS 5191 ��mm�rp„tnup4j 8 STATE REGISTRAR/LOCAL REGISTRAR �4 NY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE