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220 il6&9 25 <br />• <br />WHEN TMS COPYCAM MS THE RASED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYS1 M IT CERTIFMS THE BELOW TO BE A TRUE COPY OF THE ORIbNV14E- VMFILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEK !NATAL ST/l3TIG311CH IS <br />THE LE"L DEPOSITORYFOR VITAL RECORDS - _ <br />DATE OF ISSUANCE ±;1~? <br />S: C~O~ER <br />DEC 19 2000 tsTANTSTaT~ <br />UNCOLA NEBRASKA HEA# jw AWHWAN SERW=8 y*WjW <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH ANA HULL SWICES FT <br />CIt1D"SPORT <br />VITAL STATI$TICS <br />AKA: Jake CERTIFICATE OF DEATH <br />1 DECEDENT - NAME FIRST <br />MIDDLE LAST. <br />2, SEX <br />p'-DATEOF DEATH INt"h. Day Yearl <br />Eugene <br />Ronald English <br />male.. j <br />December 1, 2000 <br />4. CITY AND STATE OF BIRTH Iffow in USA.. namecountry) <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY - - 1 <br />6. DATE OF BIRTH (Month, Day. Year/ <br />Wood River, Nebraska <br />[Yra1 64 <br />5b MOB DAYS <br />5c. HOURS' MINS <br />Decarribe 22, 1935 <br />7. SOCIAL SECURTIY NUMBER <br />Be. PLACE OF DEATH <br />505-38-6449 <br />HOSPITAL ❑ <br />mpatiem OTHER ❑ Nursing Home <br />- <br />Sb. FACILITY • Name Nnot ms0tition, give straw and numbed <br />❑ <br />ER Outpatient <br />® Residence <br />1110 Lilley Street <br />❑ <br />DOA ❑ Other f5pecdyi <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Wood River, <br />yes ® No ❑ <br />Hall <br />ga RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER gncludjag;jle),jff <br />9e tNS(DE CITY LIMITS <br />Nebraska <br />Hall <br />Wood River <br />1110 Lilley eet <br />Yes ® Nd ❑ <br />10. RACE - While. Black American Indian. <br />t <br />d <br />1 fs <br />11. ANCESTRY (e.g.. Italian. Mexican. German etc) <br />fs <br />72. q-1 MARRIED <br />L <br />J <br />a WIDOWED <br />13 NAME OF SPOUSE 111 wile, give maiden nam otts; <br />Delores W <br />oec <br />e <br />c- <br />y) white <br />pe*) <br />Irish <br />NEVER <br />❑ <br />DIVORCED <br />MARRIED <br />14a. USUAL OCCUPATION !Gros kind o7 work data dudng most <br />14b. KIND OF BUSINESS INDUSTRY <br />- <br />15 EDUCATION [Specify ady highest grade COmPIOted) <br />i"Iti~enMc e <br />Triad Industria <br />l <br />Elemen,a y a seco day 10121 College (1-4 or 5-1 <br />12 <br />16. FATHER - NAME FIRST MIDDLE LAST <br />R <br />FIRST MIDDLE MAIDEN SURNAME <br />Earnest L <br />English <br />7 <br />Mary R. Kearney <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />Iga. INFORMANT-NAME <br />~1U~ <br />fYes. no. or unk.) in yes. give war and dates of services) ARMY <br />Yes 1 58-196 1964 RESERVE <br />Delores <br />English <br />190 IN1-UHMAN 1 MAILING AUUHt55 <br />15I REE f UH KF.U. NU.. UITY UH TUW N. S 1 A 1 t. LIYI <br />P.O. Box 455 <br />Wood River, NE <br />68883 <br />EBALME1 SI ATURE 8 LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />21 b. DATE <br />RY NAME <br />21 c. CEMETERY OR CREMA <br />T <br />O <br />A <br />/ <br />0(~ <br />❑ Budel ❑ Remoxal <br />2/5/2000 <br />~ <br />. <br />~ <br />St. ry +-+a j 's Cemetery <br />HO ME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel Funeral Home <br />❑ Creloon ❑ Mon. <br />Wood River. NE <br />P.O. Box 126 Wood River, Nebraska <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). Ibl. AND (0) I Interval betvreen onset and death <br />PART I <br />I ,a, Cardiac arrest unknown <br />DUE TO. OR AS A CONSEOU04CE OF I Interval between onset and death <br />I <br />tbl <br />and <br /> II Irl I <br />OTHER SIGNIFICANT CONDITIONS - C xiftions Cdlbb&q ro the death bid opt related <br />PART III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART <br />PREGNANCY IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />It <br />(Ages 10-54) Yes No 1-1 <br />Yes No <br />Yes. 11 No. <br />26a. <br />26b. DATE OF INJURY (Mo.. Day.. Yr.) <br />.26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident Undetermined <br />1 <br />- <br />M <br />I Suicide Pending <br />f <br />26e INJURY AT WGRK <br />26t. <br />e EOFF INJURY - hm),~, farm. weal Iactory <br />f6 <br />ffi <br />W <br />S <br />26g. LOCATION STREET OR R.F.D. NO. <br />-CITY OR TOWN STATE <br />El Homicide Investgaton <br />Yes ❑ No ❑ <br />1t <br />ladfN <br />o <br />c <br />O <br />C <br />27a. DATE OF DEATH (Mo Day. Yal <br />28s, DATE SIGNED ( o.. Day. W I <br />28b. TIME OF DEATH <br />ai <br />96,w~(Iaoov <br />10:26 am <br />27b. DATE SIGNED (Ma. Day. Yc/ <br />27a TIME OF DEATH <br />Mc. PRONOUNCED DEAD (MO. Day. Yc) <br />28d PRONOUNCED DEAD (Howl <br />a <br />11 <br />ggg <br />$ <br />M <br />EH <br />~ <br />ecember 1 2000 <br />10,: 26 aim <br />2 .1 <br />27d. To the best of my knovdedge. death occurred at the Vote, date and place and due to the <br />M. On the basis of examination and~or investigation, in my opinion tl oeowred at <br />causelsi sfated. <br />° a <br />► Itd fime. date and Place ro c <br />sue. <br />C. <br />(S1 nature and Idle) ► <br />(Signature and Title <br />• <br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />WAS CO_NSRN <br />T <br />G NTED? <br />❑ YES ❑ NO ® UNKNOWN <br />❑ <br />YES El NO <br />❑ YES 51 NO <br /> 1131. NAMt ANUAUUHt5b UVL.CKllrItl lrMTbIUAN,WHUNCHSrnTWt;MUHI:UUNITA1IUrfntTI lrypacrrnnO <br />Yr.) <br />