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1 1 ' . • . • . .:LIME - aa00lE LILtt <br />I. David Alan Ellington <br />2 SERI 3 DATE OF DERTN AMOS Om I eN1. _ <br />Male (September 19, 1999 <br />f a OTT AND STATE OF BARN a ball a USA. AmpaMMYp <br />Charleston, Illinois <br />SA AGE • W swift <br />1 55Y dS <br />UNDER 1 YEAH <br />TIDER 1 DAY <br />t DATE OF EaaM ROM Oar Nom <br />Jan 5, 1 <br />1944 <br />9, °A`s <br />'" i° "� � <br />7. SCOAL IECUi[RW NULNER <br />505 -52- 3771 <br />I <br />!r PLACE OF DEATH <br />" — °°"T"L orb+ Q ra <br />s FAC$JTY•Name PAY •rAba <br />St . Francis Medical Center <br />0 <br />III <br />EPOAAPM" 0 R,I�,. <br />Dm Q �.. ,,,,.�, <br />se. C1TY 70TH ON LOCATION OP DEAN <br />G r a n d Island <br />m mare CRY LIMITS <br />Yam No 1 1 1 <br />N COUNTY OP DEATH <br />Oa mice= • STATE <br />Nebraska <br />11 RACE • NAG LYMA OM Moms <br />Ae COUNTY <br />! Hall <br />roan <br />se. CITY. TOWN 01% LOCATION <br />Grand Island <br />STREET AND MAGER is MaMIZR OMR <br />68803 <br />4271 West Capital Ave <br />h 1I5CE CRY LAIRS <br />". 7QG N• • <br />°G IAreg <br />Sl White <br />14 USUAL OCCUPATION P.• Aw/d•p• *asap* <br />d <br />11. MCFST%!•s Wan <br />American <br />p aria! <br />Mse* <br />1.113 <br />Plumber'Excavator <br />Gomm. alcl <br />sill CO BUSINESS INDUSTRY <br />12 (� n MANNED D MOONED <br />NEYER � OIYd10ED <br />• MARpF <br />15. EDUA00011 <br />13 y � NAME OF $POD* *Nab / +.�W <br />Earlene Jenkins <br />(SPSM M'I� <br />aIpAAOt7ACA mow* <br />rat 0 Yed <br />E • C 1 �'f � p -1a Cases !1 • S•; <br />1A FATHEER.NEE Fai4T RlDOM LAST <br />Forrest Ellington <br />17 MOTHER FIRST LIODLE towed smarm* <br />Betty Talbott <br />1A � u WAS DECEASED <br />no OIA LI <br />`r N <br />EVER M US. ARMED FORCES'! <br />II WE • my mos IY <br />w w a .UN <br />/ye 'swum NAME <br />Farlene Ellington <br />18 INFORMANT swum ADDRESS !STREET ON NF 0 NO. CITY OR TOWN STATE. DPI <br />4271 West Capital Ave Grand Island, Nebraska 68803 <br />= - .� - 5101MTNRE 5 LICENSE NO ( � 3 ` ` <br />- � .,. . - . - . ...or 7 7 <br />21. ME'TIIODLTF OAiP061T10N <br />❑BIN+ Ramon; <br />215. DATE j 2l CEMETERY OR CREMATORY NAME <br />9-23-1999 !Central Max Cremation <br />Apfel- Butler- Geddes <br />EI...""•A mi °o a'°^ <br />215 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Gibbon. Nebr- -ka <br />220. FUNERAL HOLE ADDRESS !STREET OR RF.D. NO_ CRY OR TOWN STATE DPI <br />1123 West Second Street Grand Island, Nebraska 68801 <br />5 SAMMIE CAUSE !ENTER ONLY ONE CAUSE PER LINE FOR lal. 51. AND (Ell Yaavl Mown pal am maw <br />PART <br />1 <br />DUE TO. OF; A • p + ' n v T MNny C•Iwnw pnN aM n <br />Oma <br />T�}1 :T • <br />D eCON5E0Us,a OF' vP `ieart cease vain' own <br />TO. DRAS� _Di <br />'nava ammo ma. a.0 seas% <br />RI <br />FART OTHER SON FICANT CONDMONS • CoXilals LR INNIPN le am dab banal wow 1 FART N IF FEMME WAS THERE A <br />A PREGNAN N THE FAST 3 Arms, <br />[ !AAA /0.541 Yes El Na L I <br />2• AUTOPSY 1 25 WAS CASE RED TO MECCA/ <br />! EXAMINER OR f <br />•ins Ns Eli Y•1 fi No <br />26s <br />II Asoom • UnftmlmO <br />S•cd• ❑ Pans% <br />El Hogrooda Inresismon <br />2m DATE OF INJURY DLO. AN. i 25c HOUR OF 'WRY <br />.1. <br />2131 DESCRSE PIO'D INJURY OCCURRED <br />tea INJURY AT WORK <br />Yam 12 ho I <br />N <br />ar P�AC� Y ISPmc+11T. lion 5555, Y <br />' 'B ISPRIAIT <br />26y. LOCATION STREET OR RF.D. ND. CRY OR TOWN STATE <br />_I <br />- 29 DID <br />271 DATE OF DEAN Ma Dry 1Y! <br />P1 <br />213• DATE SIGNED Mb Oar n1 <br />-m - 11 m- ••• <br />264 ".. . DEAD (ABC.. . n! <br />September- 19 19 <br />2a5 TIME OF DEATH <br />.04 nm M _ <br />2131 PPANOUNCED DEAD <br />275 DATE SAINEO Olo dr n/ <br />27e TIME OF DEATH <br />M <br />270 TO5*ES moots V dare ammo Ras Rm. 014 and <br />MIAM <br />L N I <br />ISvam•Fd TAN► <br />O0ACCO USE CONTRIEUTE TO THE ( DEATI4' <br />II YES • NO IV, UR•0a7NNN <br />2; la <br />Mss WC Slue d be u <br />� u 5 <br />30a HAS ORGAN OR TISSUE DONATION SEEN <br />❑ YES ICJ <br />2, . ofaWNSMMIn <br />Me Iwo. Wla and plow <br />(Sgn wand TAM 1.N!� � <br />COHSCERED1 Sl <br />NO <br />9 3.0 Pm M <br />and s silo-. OSrn a[cvga <br />tNwN <br />WAS CONSENT WED <br />YES <br />31 NAME AND ADDRESS OF CERTIFIER MmYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) awe <br />Pt Waun Cen1n y Arty, 11 7 E lct Or Anti Tsl and, NF 68$01 <br />32. REGIS TRAR , <br />- - <br />325 DATE FILED SY REGISTRAR /Ala. Dar. r../ <br />OCT 4 1999 <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OP A 1. ,QND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALPtCORt ON, <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICE`S, VITAL R,FGORDSF <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS, r` <br />DATE OF ISSUANCE <br />4/17/2015 <br />LINCOLN, NEBRASKA <br />r <br />S f`�ANL.EY ' OP „ER- <br />201502 <br />pEP�ARTMENT OF HEALTH q R GISTRAR <br />HUMAIV,SE VICES . <br />STATE OF MEI1A4M DEPA!'11IDIt CIF QALIN AND HUMAN SERVICES FAjaA!!f Ato CIA Mg + + <br />CERT�CATE OF DEATH 9 9 : w d'1 <br />