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Rev. 11/97 Q C C C J V O K m L H LL 2 E W W R U W rn O r LL ° o� W 4, 2 Z ILLL f7 (1) STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SMVICI S FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH A1kalfr. Dq YW Warren Alton Catchpool Male I March 1, 2000 0. CITY AND STATE OF BIRTH /Nroth USA.. name country) 52. AGE - Limit Birthday UNDER 1 YEAR UNDER 1 DAY 8. DATE OF BIMH f Abr* Day. Yeah ' Hartford, Iowa IVn.I 78 5b. MOS. DAYS 5C. HOURS MMS. February 1, 1922 7. SOCIAL SECURTn NUMBER 8•. PLACE OF DEATH 508 -12 -0965 HOSPITAL: ® k"M" OTHER: ❑ *"Wg HMO ❑ ER Ou"Nent ❑ Rpiftes .. 8b. FACILITY - Name IN not inaNNNan, give weer and number/ St. Francis Medical Center ❑ DOA ❑ 00W Moe* 8c. CRY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS M. COUNTY OF DEATH Grand Island, Nebraska Y. ® No ❑ I Hall 9a. RE • STATE 9b. CONNTY 9C. CITY. TOWN OR LOCATION 9d. STMET AND WAWR 110"W" 68803 14314 CITY I. T Nebraska Hall Grand Island Michigan Avenue. v- ® ❑ 10. RACE • 10•9, "ft. Black. American Wld o T 1. ANCESTRY leg.. Masan. Maxim. Gomm, NCI 12. ® MARRIED ❑ W1001NED 15. NAME OP /I,YAak9n ry1Ny _..-- ete.11SPSeayl White IMI American NEVER DIVORCED La,�9ft Etta Novka ... 1N. USUALOCCUPATION /GnsAiMdwaAdalaAaagrtgN tlb. KIND orSUOKSS9iDUSTRV 18. EDUCATION -' of wasirg Alb. Iran N relkad) Salesman Auto Business EMrI«aary « 10.191.1 fg9ga (1 •! « 5• t 16 FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIM SURNAME Willis Catchpool Bena Gershan • 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 196. INFORMANT - NAME 'Ye"a"" d"L"wer and damn d servicnl WWII 11/19/1942- 2/10/194 Etta Catch pool 111). INFORMANIT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP) 4314 Michigan Avenue, Grand Island it Nebraska 68803 20,E LICE O. 21 a. METHOD OF DISPOSITION 2% DATE 21C. BACK MATORY.NWE .110 1/ X❑ twrw ❑ RirtgvN March 4, 2000 lGrand Island City Cemetery 22a FUNERAL AME 21d: CEMFrERY OR CREMATORY LOCATION erTVORTOVM STATE Livingston - Sondermann F.H. ❑C."'Mon ❑ Grand'Island Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.O. NO_ CITY OR TOWN. STATE, ZIP) - - -- 601 North Webb Road, Grand Island, Nebraska 68803 -4050 PART _.. _. -_. _. . _.. _.. -_ . _.. , -.. rn.. -.•- rvn 07r" (K.f` �iT y/' rV7N /, •� M��:�/ DUE TO. OR AS A CONSEQUENCE OF 1 , WaalvN flaAaaan tmrlaN aro naAr ....._. 1 OTI I f DUE TO. OR AS A CONSEQUENCE OF lei PART OTHER SIGNIFICANT CONDITIONS - Conditions con#bA g b ihe dea8n but riot renamed PART N IF :. WAS TEiERE A AUTOPSY WAS CASE REFERRED TO LIEDICAI.. ��//��, (/I1'[ (�T ( J PREGNANCY IN THE PAST J MONTHS? "'r�K/ e- "'5 J a 1J f C 1, last► Ya No va E7LAMY. CR GgRDNE , 28s. 28b. DATE OF 81JURY Ak Day Yrl 28C. HOUR OF INJURY 26d. DESCRIBE HOW KA)RY OCCURRED Accident 0 Undetermined M El Suicide o Pending 21Te. INJURY AT WORK 261. PLAe E (t INJURY % tit k . farm. skeet. lsCtry 269. LOCATION STREET OR R.F.D. NO, CITY OR TOWN - ❑❑ ❑ CSC bu"n% SOacaY/ Hpnit•ide Invesnganon Yes No 272. DATE( DEATH /Aker. DIY ,Y�r.EJ� -- `999. DATE 99T1p IMw aw 1h; .'m a 27b. DATE SIGNED'/Aka. Day Yr/ 7C. TIME OF DEATH 28C. PRONOUNCED DEAD tW. Dry, Y►1 2Be, PRONOUNCED DEAD PFaw, V p J �/ y . To 9w l d my k ot:ctared the and dace and due to 1M 28a. OR ft b9W of exantktaaort andr« 4 vew ft ih my egYtkn daa91 dGCurnme ■ oalwelal awed. b the lints, dale and daft and due lo M cow" skad and tae 229. [NOT USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION qqEN CONSN "aw 30.b WAS CONOff- DRMlTED? 7 YES ❑ NO ❑ UNKNOWN ❑ YES NO ❑ YES aNO 31. NAMEWO ADDRESS OF CERTIFIER IPHYSICMN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI ITypa or ith" Q01caitti. rn.O. -W N, s ►- t~cc,LvQ Sstu.LCf N C) 32a. REGISTRAR 32b. DATE FILED BY REOISTRAIR mss. AW ftj '. FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part il ................... _TMV ..... ..................... NSC....................................................... .............................................................. . ....................................................................................................... ................ ... Census Tract No. Work ....................................................................................................................................................................................................................................................... ............................... . UC.....:................................................................................................................................................................................................................... ............................... Reject.............................................................................................................. ............................... ................................ ............................... ... Printed with 9" Ink en Ne"hid,a/N hereby certify this to be a true and correct copy of the original Vwith the State of Nebraska by III GENERA! NOTARY -Slate of Nebraska Signed in my presenc da f 1, ?ia,��r �1) vC) TERRYL• LOSCHEN MY Comm. "Ezp,� Notary Public