SEC FORM 4 SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
 
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
SEVERANCE H LEIGH

(Last) (First) (Middle)
14282 E. CALEY WAY

(Street)
AURORA CO 80016

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
LIFELINE THERAPEUTICS, INC. [ LFLT ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
04/18/2005
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 04/18/2005 C 200,858 A $0.5 200,858 D
Common Stock 04/18/2005 C 126,884 A $2 327,742 D
Common Stock 04/18/2005 C 5,077 A $2 5,077 I By Wife
Common Stock 04/18/2005 C 81,391 A $2 81,391 I By Trust(1)
Common Stock 04/18/2005 C 45,864 A $2 45,864 I By Trust(2)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Convertible Note $0.5 04/18/2005 C 200,858 02/08/2005 04/18/2005 Common Stock 200,858 $0.5 0(3) D(3)
Bridge Note $2 04/18/2005 C 5,077 02/03/2005 04/18/2005 Common Stock 5,077 $2 0(3) D(3)
Bridge Note $2 04/18/2005 C 126,884 02/04/2005 04/18/2005 Common Stock 126,884 $2 0(3) D(3)
Bridge Note $2 04/18/2005 C 81,391 02/04/2005 04/18/2005 Common Stock 81,391 $2 0(3) D(3)
Bridge Note $2 04/18/2005 C 45,864 02/04/2005 04/18/2005 Common Stock 45,864 $2 0(3) D(3)
Bridge Note Warrants $2 04/18/2005 C 5,077 04/18/2005 04/18/2008 Common Stock 5,077 $2 5,077 I By Wife
Bridge Note Warrants $2 04/18/2005 C 81,391 04/18/2005 04/18/2008 Common Stock 81,391 $2 81,391 I By Trust(1)
Bridge Note Warrants $2 04/18/2005 C 45,864 04/18/2005 04/18/2008 Common Stock 45,864 $2 45,864 I By Trust(2)
Bridge Note Warrants $2 04/18/2005 C 126,884 04/18/2005 04/18/2008 Common Stock 126,884 $2 126,884 D
Unit Warrants $2.5 04/18/2005 C 5,077 04/18/2005 04/18/2008 Common Stock 5,077 $2 5,077 I By Wife
Unit Warrants $2.5 04/18/2005 C 81,391 04/18/2005 04/18/2008 Common Stock 81,391 $2 81,391 I By Trust(1)
Unit Warrants $2.5 04/18/2005 C 45,864 04/18/2005 04/18/2008 Common Stock 45,864 $2 45,864 I By Trust(2)
Unit Warrants $2.5 04/18/2005 C 126,884 04/18/2005 04/18/2008 Common Stock 126,886 $2 126,884 D
Explanation of Responses:
1. By Profit Sharing Plan and Trust.
2. By Pension Plan and Trust.
3. Convertible and Bridge Notes were exchanged for Common Stock.
Leigh H. Severance 06/22/2005
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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