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`'Y'�� Cl f'� m rn cDi� � � � �� O. � f� = r� c_ � �'" iy � '�� !� 2 � � � � � � Q � 4 \ x � � � O -� O ,,,�� � � O �E�„ �r - Q �'`� +_ c�n � � a a�o o � �..� � < v l � � �"' A � N ! � � � � � � y � (h ^ � ,� � ^a � � � , ,� ��+- ._.__._...__. .. _ .... _ --.... _ ___ ._ .... � WMEN THYS COPY GI/t1�3 TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAK V/CES S1^81E11�IT CERI�ES TFE BELOW TO BE A TRUE COPY OF THE ORfQ/NAL RE._ , l!��Y1Tl�/ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATISTI. _ _ _, •�$, THE LEOAL DEPOSITORY FOR V/TAL RECORDS. "� j = ��{ -j�� L.. _ � DATE OF/SSUANCE ��""'"_ � U � `' JA�I ` ,. �z � „�►,�� ..w..� 4 ��`��0`��i�-�� _. ,��A� i UNCOUV.NEBRASKA HEALTH AMD HUA�AN SE��I M= I -' :.-� _.--� � STATE OF NEBRASKA-D E P A R'I'ME N T O F E�.ALTH ANp HUMAN gERViE�.S : _ " p�r VfTAL STATISTICS -- -- - -: --' __ � -- CERTIFICATE OF DEATH -__--- '-- I.DECEOEN7-NAME FIRST MiDDLE LAST 2 SEX 3.-r�DATE OF DEATH iMonm.Day Yead Albert NMI Madsen Male December 16 1999 1.CITV AND STATE OF BIRTH p/rrol in U SA..name counhyl Sa.AGE-Last 8itlhtlay UNOER t VEAR UNDER t DAV 8.DATE OP&FTH /Mpiph.Dey.Yseil I IVrs.l Sb.MOS � DAVS St.HOURS' MINS. � A 14 1 7.SOCIAL SECURTIY NU 8a. PLACE OF DEATN � 505-12-0434 HOSPITAL � inpaGent OTHER � NurSu+gHome ep.FACIUTV�Name /Hnohns�iNlan.gives�reetarrdnumDer/ � Ea Outpatiem ❑X Res�aance • 2715 O'Flanria an .S�E�t ❑ �A ❑ O�ner�Spec�hi ic.CITV.TOWN OR LOCATION OF DEATH Btl.INSIDE qTV UMITS Be.COUNTV OF OEATH Grand Islar:d "^� � "� ❑ Hall 9a.RESIDENCE�STATE 9b.COUNTY 9c.GTV.TOWN OR LOCATION 9tl.STREET AND NUMBER /InNudingZiO CoOel 9e INSIDE CITV IIMITS Nebraska Hall Grand Island 2715 O'Flannagan, 68803 �es� No❑ 10.RACE-(e.g.,Whi1a.Biack.American Indian. 11.ANCESTRY le.g..1181ian,Mexican.German,etcl t2�MARRIED ❑WIDpWED 13.NAME OF SPOUSE (H wAe.givs maiden iwme/ e1t.11SoeaN1 ISpetMl NEVER DIVOFCED White American Elsie Harvey Ua.USUAL OCCUPATION /Giva kindo/wpk Uprre dwiny mpsl f Ib.KIND OF BUSINESS INDUSTRV 15.EDUCATION �SpBuN only n�gnaet p�Wa compbtsd) olwnnt�ng�He.even�lreliredl Ebmenuryw$e�ontlary IO-�21 Cdlega ii��o�5•i Farmer A iculture 2+ 18.FATHER-NAME FIRST MIDDLE LAS7 77 MOTHER FIRST MIODLE MAIDEN SURNAME -- � j'i:t:�:1 �f i �-��i`i 1 W S ECEASED EVERIN US.ARMED fpRCES? 19a.INFORMANT-NAME � � IVes.no or unk.i I pl yes.g�ve war antl Oales ol s�rviees� � tpp.INPORMANT MAtLMG AOD ESS ISiREET OR R.FA.NO..CITY OF TOWN.STATE..':P) �- � � � �., CSO1 20.EMBAL ER-SIGNATUREBUCENS O.• 2ta.METHODOFDIS OSiT10h 2tb.DATE � 21c.CEMETEHYORCREMn'OPv N,,, AME �e l..elYle Y'y -#�'ia3 (��e� �Remosal Dec. 20, 1999 Westlawn Memorial Park � - 22a UNERAIHOME-NAME 27tl CEME7EFV ORCREMATORVLOCATION GTV pRTOWN STATE Kleine Ftiineral Home �Cremalron �o�,a��o� ; Grand Island, Nebraska 22p.FUNERAL HOME ADDRESS ISTREE7 OR R.FD.NO.CITV OR TOWN.STATE.21P� 3213 W. North Front St. Grand Island Nebraska 68803 IMMEDIATE CAUSE . (ENTER ONLV ONE CAUSE PER LINE FOfi lal.Ib1.AND�cll � Inlerval between onsel antl Oeain ART ,, � � C r lal j � DUE 70.OR AS A CON OUENCE OP I Inlerval belween onset antl Oeatn i �e� i DUE 70.CR AS A CON�EOUENCE OF �� , Ir„enal betwiuF:^w�aad c:�tn-.___..__ �� O7HER SIGNIFICANT CONDITIONS-ConOiuons conVibuting io the Oeat�but not relatea PAR7 ill iP FEMAIE.WAS THERE A 2 AUTOPSV 2.WA CASE REFERRED TO MEDICAL PART GREGNANCV IN THE PAST 3 MONTHS7 AMINER OR CORONER� � II t IAges�O-Sd� Ves No Ves No Yes No 26a 26b DATE OF INJUfiV /Mo..Day Yt/ 26c HOUR OF INJURV �26d.DESCRIBE HOW INJURV OCCURRED ❑ ACCMem � UntletermmeA M \� � SwcMe � Pend��g 26e.INJURV AT WORK 261.PLACE OF.INJURY-At home,fa�m.sveet.ladory 26g.LOCATION STREET OR RFD.NO CiTv OR TOWN STATE J ❑ ❑� otlice bwltivy etc. /Specily/ � NomiCWa Irn�slgatqn VK NO J 27a�DA7E OF DEATH i,Mo Oay Yr./ 28a DATE SIGNEO /Mo..Day.Yr 1 28� 71ME OF DEA7M /� S< L' b ,.a', M �� .DATE SIGN D ( ..Oay Yrl 27J!TIME OF DEATH 8+a�� 2&.PRONOUNCED DEAD /Mo-Day,Ycl 2Btl.PRONOUNCED DEAD lHourl �� Z- �. .'� ` /�0 M ��i� M � 8,w� �� .To t e best my knowled e. a occe`etl at Ihe time.Oale antl D�a and due to tne ��c� 28e.On tM Dasis d exemmauon and�a invesugauon,m my opmon tleath occurretl at causelsl slaled. . � � a me��me.aa�e a�d o�ace ano oue io ma caose�si sia�ed... 19 naWre and Ti11e � � naWre an0 Tilb .DID 700ACC0 USE CONTRIBUTE TO THE D6ATH7 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? . WAS CONSENT GRANTED� � VES NO ` � UN OWN � VES NO � � VES �R� 31.NAME AND ADDHESS OF CERTIFIEA IPHVSICIAN,COFiONEA�S PMVSICIAN OR COUNTV ATTORNE�I /iype a Prmll Gordon ,7. Hrnicek 729 N, ter Grand Island Nebraska 68803 32� RE6ISTRAR J2E.DATE FILED BV REO�STRAR /Ab..OIy.YrJ DEC � 0 . -_ . _ __�_._...._--�---- - - -- The South One Htmdred Feet (100 Ft) of Lot Seven (7) in Block Three (3) Dickey Second Subdivision City of C=rand Island, Hall Cotmty, Nebraska..