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Lot Nine (9), Block Two (2), Capital Heights Third Subdivision, being a part of the Southwest Quarter (SW 1/4) of
<br />Section Two (2), Township Eleven (11), North, Range Ten (10), West of the 6th P.M., Hall County, Nebraska
<br />WHEN TH 13 COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAAISER WCES
<br />SYSTEMr IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORWdWA MF
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SET! -7
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />JAN 2 0 2000 20000203 ASSISTANI_ $SE REGISTRAR 94 -
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN_SERV�4-Y. `
<br />zfT
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FiiA96 'ART-
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />iI . DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX 3. -DATE OF DEATH /Moron. Day. Yearl
<br />Frank Warren Laird
<br />Male January 12, 2000
<br />4, CITY AND STATE OF BIRTH td not n USA_ name countryl
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />=
<br />D
<br />5b MOS I DAYS
<br />c�
<br />o
<br />Q
<br />November 12, 1924
<br />e
<br />8a. PLACE OF DEATH
<br />506 -32 -0206
<br />n
<br />HOSPITAL 0 Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />n
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other lSP-4,
<br />n=
<br />8d. INSIDE CITY LIMITS
<br />Be . COUNTY OF DEATH
<br />Grand Island
<br />3>
<br />N�r
<br />rn
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />n
<br />M
<br />n
<br />0 >
<br />Z
<br />Grand Island
<br />4206 Vermont Ave. 688 3Yes ® No ❑
<br />10. RACE - (a. g.. White. Black. American Indian
<br />17. ANCESTRY le. g.. Italian. Mexican. German, etc)
<br />70
<br />crnJ
<br />13. NAME OF SPOUSE W wile. give maakn name/
<br />rn
<br />O
<br />NEVER DIVORCED
<br />M R
<br />Lucille Perkins
<br />114a. USUAL OCCUPATION !Give klrMot work done dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />o!working/de, even itrehredl
<br />Carpenter /Foreman
<br />General Construction
<br />Elementary or ondary (0 -121 College U.4 or 5-I
<br />1L
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />t 7. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />i Clarence Laird
<br />Mary Finley
<br />18 WAG DECEASED EVER IN U.S. ARMED FORCES?
<br />CZ)
<br />C26
<br />1�
<br />1 l
<br />19b. I %-ORMANT tAAILING ADDRESS (STREET OR AT D. NO.. CITY OR TOWN. STATE. ZIP)
<br />4206 Vermont Ave., Grand Island, NE 68803
<br />- SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />2lb. DATE 21c
<br />Af
<br />m l �
<br />-Md �/MEER
<br />/ `��C^1.�(.'- ✓�/�CJ��V''y
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<br />r..
<br />22'. - UNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />® Cremation ❑ Donation
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, Nebraska 68801
<br />23 IMMEDIATE CAUSE (E TER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) I Interval between onset and dean,
<br />PART
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<br />Lot Nine (9), Block Two (2), Capital Heights Third Subdivision, being a part of the Southwest Quarter (SW 1/4) of
<br />Section Two (2), Township Eleven (11), North, Range Ten (10), West of the 6th P.M., Hall County, Nebraska
<br />WHEN TH 13 COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAAISER WCES
<br />SYSTEMr IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORWdWA MF
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SET! -7
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />JAN 2 0 2000 20000203 ASSISTANI_ $SE REGISTRAR 94 -
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN_SERV�4-Y. `
<br />zfT
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FiiA96 'ART-
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />iI . DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX 3. -DATE OF DEATH /Moron. Day. Yearl
<br />Frank Warren Laird
<br />Male January 12, 2000
<br />4, CITY AND STATE OF BIRTH td not n USA_ name countryl
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH (Monet. Day. Year)
<br />5b MOS I DAYS
<br />Sc HOURS' MINS
<br />York, Nebraska
<br />(YrsI 75
<br />November 12, 1924
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -32 -0206
<br />n
<br />HOSPITAL 0 Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />6b. FACILITY - Name /Hnof inselulan. give street and number/
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other lSP-4,
<br />8c *CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be . COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9tl. STREET AND NUMBER !lnc/uding Zip Code/ 9e INSIDE CITY LIMITS
<br />Nebraska
<br />all
<br />Grand Island
<br />4206 Vermont Ave. 688 3Yes ® No ❑
<br />10. RACE - (a. g.. White. Black. American Indian
<br />17. ANCESTRY le. g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE W wile. give maakn name/
<br />etc "Specify) White
<br />�vll
<br />ISpecNl American
<br />NEVER DIVORCED
<br />M R
<br />Lucille Perkins
<br />114a. USUAL OCCUPATION !Give klrMot work done dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />o!working/de, even itrehredl
<br />Carpenter /Foreman
<br />General Construction
<br />Elementary or ondary (0 -121 College U.4 or 5-I
<br />1L
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />t 7. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />i Clarence Laird
<br />Mary Finley
<br />18 WAG DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT -NAME
<br />!Yes. - a unk.l yu;. gore war and dates of services)
<br />( Yes: T II 1 -25 -44 4 -25 -46
<br />Lucille Laird
<br />19b. I %-ORMANT tAAILING ADDRESS (STREET OR AT D. NO.. CITY OR TOWN. STATE. ZIP)
<br />4206 Vermont Ave., Grand Island, NE 68803
<br />- SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />2lb. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />-Md �/MEER
<br />/ `��C^1.�(.'- ✓�/�CJ��V''y
<br />❑Burial ❑Removal
<br />Jan. 17, 2000
<br />Central Nebraska Crematior
<br />22'. - UNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />® Cremation ❑ Donation
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, Nebraska 68801
<br />23 IMMEDIATE CAUSE (E TER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) I Interval between onset and dean,
<br />PART
<br />(al
<br />UUt 111, 11" "A GUNStUUtNUt Uhl V Interval between onset and death
<br />y I
<br />(b)
<br />DUE TO. OR AS A CONS50UENCE OF
<br />Interval between onset and deem
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to 91e death but not related PART III IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS?
<br />II
<br />.EXAMINER OR CORONER'!
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a
<br />26b. DATE OF INJURY tMo. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F] Undele-ced
<br />M
<br />El C...de ❑ Pending
<br />Homicide InveSlgallpn
<br />26e. INJURY AT WORK
<br />Yes No
<br />❑ ❑
<br />261 PLACE OF INJURY' ,t home farm. street. factory
<br />oXlce Mating, etc. /Specify/
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (Aldo. Day. Yr.)
<br />28a. DATE SIGNED ;Mo., Day. Y0
<br />28b TIME OF DEATH
<br />r uy,
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<br />27b. DATE SIGN (Mo.. Day Yr/
<br />� � 0�
<br />27c: TIME OF DEATH
<br />�llr• ..J�/ M
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr/
<br />28d. PRONOUNCED DEAD /Hour)
<br />M
<br />27d. To the be of my k de curretl at Me lime, date era place and due to Ine
<br />causelsl staled.
<br />20e. On die basis of examination antlla investigation, in my opinion death occurred at
<br />the time. date and place and due to the causes) stated.
<br />(Signature and Tills
<br />(Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE HE D TH7
<br />OR TISSUE DONATION BEEN CONSIDERED'
<br />30.b WAS CONSENT GRANTED'
<br />[7RGAN
<br />❑ YES ❑ NO UNKNOWN
<br />❑ YES NO
<br />❑ YES 10 -
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY; !Type or Printl
<br />Gordon J. Hrnicek M.D. 729 N. Custer Grand Island, NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /Ado.. Day. Yr./
<br />JAN 19 20M
<br />
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