DENVER (AP) — The death of a woman who was partially paralyzed in the Columbine High School shooting has been ruled a homicide, raising the death toll of the 1999 attack to 14.

Anne Marie Hochhalter died Feb. 16 of sepsis — a reaction to infection — and complications from her paralysis were a “significant contributing factor” in her death, the Jefferson County Coroner’s Office said in an autopsy report obtained Thursday. She was 43.

At the time, her family and friends suspected her death was due to natural causes related to her injuries in the shooting, which immediately led to the deaths of 12 students and a teacher. The two student gunmen killed themselves. Due to the role her paralysis was suspected of playing in her death, the investigation was transferred to the office that also reviewed the deaths in the school shooting.

Hochhalter struggled with intense pain from her gunshot wounds in the years following the shooting, but fought hard to to overcome the complications of her injuries and remain positive, family and friends said. She was tireless in her drive to help others, including people with disabilities and members of her family, and she loved dogs, they said.

Hochhalter chose to forgive the mother of one of the gunmen, writing in a 2016 letter to Sue Klebold: “’A good friend once told me, ‘Bitterness is like swallowing a poison pill and expecting the other person to die.’ It only harms yourself. I have forgiven you and only wish you the best.”