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1. DECEDENTS•NAME (First,.. MIddia :.. Last, Su lbn
<br />Edward Earl Clark
<br />2. SEX :
<br />Male
<br />3. DATE OF DEATH (Mo,Day,Yr.) -
<br />June 15, 2012
<br />I. DATE OF BIRTH (No., Day, Yr.)
<br />October 3, 1938
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH .
<br />Beatrice, Nebraska
<br />6a AGE -Last Birthday
<br />(Yn.)
<br />73
<br />5b. UNDER 1 YEAR
<br />6c. UNDER I DAY .
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE.
<br />SOCIAL SECURITY NUMBER
<br />505- 42 -0506
<br />Si. PLACE OF DEATH
<br />ceF.Ny
<br />la°el.: ® � 0 Parsing swats,* � Honisn.TC ❑ Hospice u
<br />IW�
<br />0 0 Dacedeffs Horns
<br />❑ D0A ❑ )
<br />FACILITY-NAME Ob. FACI-NAME (E nor saloon. YH Wt and m.KM r)
<br />Veterans Affairs Medical Center
<br />Sc. . CITY OR TOWN OF DEATH (Include Tip . Code)
<br />Grand Island 68803
<br />td COUNTY CF DEATH >s.
<br />Hall
<br />S. RESIDENCE-STATE
<br />Nebraska `
<br />lib. COUNTY '.
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand island
<br />Ed amen AND NUMBER :
<br />1804 Idlewood Lane >
<br />Ile. APT. NO.
<br />:St.21P CODE
<br />68803
<br />9g. INSIDE CITY UNITS
<br />® Yes ❑ N O
<br />10... MARITAL STATUS AT TIME OF DEATH ® Monied' ❑ Never Monied
<br />id ❑ unkn ,m
<br />0 Unified. butespartad D Widowed ❑ Dvmw
<br />10b. NAME OF SPOUSE (Fink` Isddle. Lot, &OM) E &He. Slvs maiden nrla.
<br />Leon Mae Lineweber
<br />11. Fs (First, Middle, ',Lank IS ' .
<br />Sharp Brown Clark
<br />12. MOTHER'S -NAME (MM. MNIdN. Mahlon Samna)
<br />Martha Lena Davis
<br />13. EVER IN U.S. ARMED FORCES? GM dates of service If Yea
<br />, No,unk.) y O6/29/i .' . _ , ,.,,. i o
<br />(Ye or
<br />14a. INFORMANT -NAME
<br />Leah Clark
<br />144. RELATIONSHIP. TO DECEDENT
<br />S ..
<br />15. METHOD OF DISPOSITION
<br />D I ❑Dea.aer
<br />ex ins. e nlw.rinwll
<br />O Cns.
<br />semmal 0 0 1 . lPeshM
<br />16.. EMBALMER RE
<br />/ . l,.r
<br />let. UCEENSSE
<br />/1/4//i
<br />16c. DATE (Ma. Day, Yr.)
<br />June 21, 2012
<br />1Sd CEMETERY, CREMA OR OTHER LOCATION. CITYITOWN .. ESTATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />t7e.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Etats)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska
<br />17b. 2IP Cods
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />awoo.Motaeay wowedaw ara DO NOT *Ow Woa ace moor tees oodles anew. ; APPROXIMATE INTERVAL
<br />a PORT OW Mt d MMNolmo..Am eo wry,orc.mus ho
<br />b showing lee Wormy. NOT ASIIM IMI. MON NW me mum au a Si. fed. AM aremoni Ones I MCMMry.
<br />r piratorya /net, or - wNM auto It NYn wq"a
<br />:..' &MEDIATE CAUSE: i onset to death
<br />IMMEDIATE CAUSE (Filial pi - :..
<br />wr. ewwklon 1"41ins a) k- QC a‘, n 1Jr�?S L1R0.c1
<br />"cc 6 N c e
<br />)
<br />DUE TO, OR AS A CONSEQUENCE OF: : onset to dmh
<br />�
<br />SsquMtlMly list conditions, If b) . 111 {,�
<br />toth mum ( c � Ite L�Ar vu;* o.S o S
<br />any. laaarg sell
<br />anea DUE TO, OR AS A CONSEQUENCE OF. � ft
<br />MM onsettoda
<br />Enter the UNDERIYNG CAUSE c) i�w\ Ct w... N , e Qnc .a {\t c c�t‘ tin
<br />&lemmaa or Injury (hit &Noted;. DUE TO, OR AS A CONSEOUEIIUE OF: - A
<br />t.ayset „mom d) ...
<br />LAST C ,% CtLS \Ve .1 1.aMelRacx rStcbA
<br />i onset to &NM
<br />r .
<br />15. WAS MEDICAL. EXAMINER
<br />OR CORD�IEit CONTACTED?
<br />❑ YES NO
<br />15. PART IL OTHER SIGNIFICANT CONDn1UNS•Condltlaa contributing
<br />to the death but not moulting In the underlying c is given in. PART L
<br />`
<br />: e - - -
<br />20. IF FEMALE:
<br />ONot pregnant past &thin p year
<br />❑Prsanent at ums of death
<br />❑Nat pregnant, but pnamntwltNn 42 days or death ;..
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑unlmownIf pregnant MUM the wet year
<br />21a. MANN OF DEATH
<br />*Mural ❑ Homtcda
<br />❑ Accident 0 W dhl inseatlaatlon
<br />❑Suicide ❑ Could not be determined ...
<br />:.21b. IF TRANSPORTATION NJU
<br />: ❑
<br />i.I t Pasoan,"
<br />❑Podiatrist'
<br />❑ Other (Epeclfy)
<br />21c. WAS ANA PERFORMED?
<br />DYES
<br />21d. WERE AUTOPSY FNDINGSAVAILABLE
<br />TO COMPLETE GUISE OF DEATH?
<br />❑ YES to 10
<br />l
<br />22a. DATE OF INJURY (Ma, Day, Yr.)
<br />1 220. TIME OF INJURY _
<br />I L m
<br />22c. PLACE Off INJURY At horns, Mn, abut, factory, MIlm building. eaatruddan sole,: its. (SpeMKO
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />D YES
<br />222 LOCATION OF INJURY - STREET & NUMBER APT. NO. CITY/TOWN STATE aP CODE
<br />23a. DATE OF DEATH (Ma, Day, Yr.)
<br />a
<br />Y
<br />s ;
<br />24a. DATE SIGNED (Ma, Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />22b. DATE SIGNED (Ma, Day, Yr.)
<br />0-I .6
<br />23c. TIME OF DEATH
<br />. 4 .m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br /><=
<br />: 24d. TIME PRONOUNCED DEAD
<br />m
<br />o 0 occurred tie
<br />` a: 2W:T to of my . • (SgmW and at
<br />o '
<br />/
<br />• ' UTE TO ' DEATH?
<br />Y ES ❑ • « 0 PROBABLY ❑ UNKNOWN
<br />Sm., data and �
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />B
<br />TISSUE
<br />24e. On the basis of wandntllon
<br />at the tee,: den and place
<br />DONATION. BEEN CONSIDERED?
<br />et, NO
<br />andforinvsetgation, In my opinion death oownd
<br />and due to the Gauen &) Mated . (SigneYlla and Tills)
<br />Sib. WAS CONSENT GRANTED?
<br />Not Appxo.ble if 25. is NO ❑ YES NO
<br />27 NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN 2ASSISTA CORONERS PHYSICIAN OR COUNTY ATTORNEY)
<br />®1 e c , e 1 ,' \\ 11 Y •• - • . La•..
<br />(Type • Print)
<br />®.. 1 Iii t ► w ,\1
<br />-•
<br />tote • SIGNATURE
<br />4r r," t , ,
<br />Mb. DATE FILED BY -�.. (Mo•, Day, Yr.)
<br />JUN 2 8 202
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT-OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL kE COi D,
<br />DATE OF ISSUANCE
<br />07/02/2012
<br />LINCOLN, NEBRASKA
<br />201304985
<br />STANLEY S. Op'ER
<br />ASSISTANT STATE REGISTRAR
<br />DERARTMEntr OF }-
<br />HUMAN SER yICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />W D TIFICaTE o f fEATH ? 2 _ ? 9 8 '
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