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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD,, F! THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE'"U FEB 1999 200001422 A SSIStA LINCOLN, NEBRASKA HEALTH AND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESV _ J 0 T = _ VITAL STATISTICS CERTIFICATE OF DEATH `= 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX - '�lMOnM Day. Y"11 Glenn Albert L 0. CITY AND STATE OF BIRTH lllno,h U.S.A.. name couney) 58. AGE -Last eintday UNDER 1 YEAR UNDER I DAY I S. DATE OF BIRTH IMorrh. Day. Year) (Yrs.) Sb. MOS. DAYS 5c. HOURS' MINS. Hastings, Nebraska 81 September 7. 1917 T SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH HOSPITAL: U Inpatient OTHER: ❑ Nursing Home 504 -03 -7028 -- -- ❑ ER ONpallent ❑ Residence 8b. FACILITY - Name (d nor mi (table, gms abed and number) St. Francis Medical Center ❑ DOA ❑ 0thar fSpecd1 Sc. CITY. TOWN OR LOCATION OF DEATH So. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island • Ves ® No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /MckrditVZO c6%832 go. INSIDE CRY LIMITS Nebraska I Hall I Doniphan 1208 W. Bartelt Ave. I Yes No ❑ 10. RACE - (e.g., While, Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 't! 12. ® MARRIED ❑ WIDOWED 73. NAME OF SPOUSE ld wile. give maden name) etc.) 1SDecrly) White (SPOCM J I French /Canadian NEVER DIVORCED Lure Rader 14a. USUAL OCCUPATION (Give kind of w&* dom cW moat , -,13 14b. KIND OF BUSINESS INDUSTRY O 1 I 15. EDUCATION (Specify only fighsq grads complele it Elementary or Secondary 10 -121 College 11 -a or 5 -1 of waking life, @von #,*kiwi) 16. FATHER -NAME FIRST MIDDLE ST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME 18. WAS DECEASED EVER IN U.S. ARMED FORCES? ' 9a INFORMANT -NAME (Yes no or unk.l I IN yes. give war and dates of services) ) No ILlliryi, LaRrip Wife 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 208 W_ Rnrt-alt Amp-, Dani nn- NplivnizIr-n fib$ -47 20.E MER - SIGNATU LI ENO. �� 7 22 21a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME Burial ❑ Removal 2a. F NERAL E - NAME 21d. CEMETERY O CREMATORY LOCATION CITY OR TOWN STATE ❑ Gremalial ❑ Donation 22b. FUNE HOME ADDRESS (STREET OR RF.D. NO.. CITY OR TOWN. STATE, ZIP) 1225 N_ Elm Ave, 14aqtjng.-,, Nphrqqlcq fiR9Q] 21 IMMEDIATE CAUSE (ENTE ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)l I Interv],L)atween onset and deam PART •_' % 1 '�R 0 I 1 'I 1 t I l j DUE 10. OR AS A CONSEOUENeE OF I Interval between onset and deam I I fb) DUE TO, OR AS A CONSEOUENCE OF: I Interval between onset and dear, I (d1 OTHER SIGNIFICANT CONDITIONS = Conditions contributing q 111a deem but not relete0 PART 2a. III IF FEMALE. WAS THERE AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY 11 NT. IN THE PAST 3 MONTHS? EXAMINER OR CORONERS (Ages 10 -54) Yes NoEfl yes No Yes 0 No 26a. 26b. DATE OF INJURY /MO.. Day. Yr.) 26c. HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED ❑ Accident F] Undetermined M 11 Suicide Ej Pending 26e. INJURY AT WORK 261. PLAe E OFnINgdB,RY %At home, farm. street. factory bu,ldi Spe 26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ o11fi8cc y 27a. DATE OF D TH /MO.. Day. Yr.) 28a. DATE SIGNED (MO.. Day Yr) 28b TIME OF DEATH % M 27b, DATE SIG D (MO. Day. Yr.) 27c, TIME OF DEATH 28c. PRONOUNCED DEAD (MO.. Day, Yr) 28d. PRONOUNCED DEAD /Hour/ Z6 g IZ Ah� M M $ 8 � 27d. 7o the Deld d my knowledge, em occurred M dne 8me, to and dat due to the 2Be. On the basis d examination ard,a kweeligeaorl, in my Opinion death occurred at � � causelsl stated. v b the time. date and place and due to the causes) staled. IS. nature and Tito (Signature and Title 29, DID TOBACCO USE CONTRIBU E DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES F1 NO ❑ UNKNOWN ❑ YES �NO 1:1 NO 9 NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Pnnl! Azariah Kirubakaran M.D. 2116 W. jajoley Ave., Grand Island, NE. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.) N