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Z <br />x <br />M CP v> o —I <br />{ M <br />m O� <br />p <br />J M 713 yD I p ss <br />i u <br />m :4 <br />9C <br />x, rn <br />$Gettig? <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAIN(.SERYICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORQ -01 C iEw- <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SFIlCfifilS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />SEP 2 9 2000 ASSIS 1'AN� SSA TE REGISTiTAni <br />LINCOLN, NEBRASKA HEALTH AND HUMAN_- -SERVICEIf 3YMN ' :`f <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV1PW­FIN�_VCCA3W3SIJPPi_ <br />VITAL STATISTICS .. = <br />CERTIFICATE OF DEATH <br />1 DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH !Month Day year, <br />Carl L. Prawl Jr. <br />Male' <br />August 28 2000 <br />4. CITY AND STATE OF BIRTH df noon USA. name country; <br />la AGE Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16 . DATE OF BIRTH tMonih. Day Year, <br />5b MOS DAYS <br />5c. HOURS MINS <br />Hastings, Nebraska <br />IVrsJ <br />61 <br />Au St 29 1938 <br />9 _ <br />7 SOCIAL SECURTIY NUMBER <br />Sa. PLACE OF DEATH <br />Inpatient OTHER Nursing Home <br />508 38 3026 <br />HOSPITAL <br />ER Outpatient Residence <br />t <br />Bb FACILITY - Name /lt not institution, give street and number) <br />St, Francis Medical Center <br />DOA Other tSpeaty <br />& CITY TOWN OR LOCATION OF DEATH <br />8d INSIDE CITY LIMITS Be COUNTY OF DEATH <br />,,,a <br />Grand.-- ISlaia4 _.. <br />_ Yes X N ❑ <br />ft S E • StATE.. 9b - TV .' - <br />., -. Al <br />9d_ "CITY _._ - L _ _.'__. - <br />-. e IN 1 E LIMITS <br />- .. <br />Nebraska Hall <br />Grand Island <br />119 E. 16th St. 68801 Yes No ❑ <br />10 RACE - (e.g., White. Black. American Indian <br />11. ANCESTRY le g.. Italian. Mexican, German, etc) <br />t2 MARRIED WIDOWED <br />13 NAME OF SPOUSE ttl wde give malden name; <br />etc I ISpecdy) <br />(Specityl <br />American <br />I <br />NEVER DIVORCED <br />Barbara Shepherd <br />White <br />German/ <br />MARRI <br />- - -- <br />14a. USUAL OCCUPATION (Give k1nd0 /w0rk done during most IdD KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecily only highest grade completed) <br />of working life. even iftetired) Elementary or Secondary (0 -12) College I1 4 c, S <br />16. FATHER •NAME FIRST MIDDLE LAST 17 MOT R FIRST MIDDLE MAIDEN SURNAME <br />(Dec.) Carl L. Prawl Sr. (Dec.) Edith NMI Shipley <br />16 WAS DECEASED EVER IN US. ARMED FORCES? �J <br />ietnam Era <br />19a INFORMANT NAME <br />(Vas. no. or unk.) (It yes. give war and dates of services!' <br />Yes 1956 - 1976 <br />- <br />19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN. STATE. ZIP) <br />119 East 16th Street, - <br />29 EMBALMER - SIGNATURE B LICENS la METH DOFDSPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME <br />Not Embalmed ❑ Burial ❑ Removal Aucq 29, 2000 Central fle�vrAM Cremation <br />22a. FUNERAL HOME . NAME 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Kleine Funeral Cremation ❑ DOndtiOr Gibbon Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR P.F.D. NO CITY OR TOWN. STATE, ZIP) <br />3213 W. North.Front Street Grand Island Nebraska 68803 -_ <br />23 IMMEDIATE CAUSE -T-I& ( \� ({ENTER ONLY ONE CAUSE PER LINE FOR '.al Ib). AND (c)1 Interval between onset and deal <br />PART A QU "�\ \`I-�� C� (' R kL_U `i -- ",, � Wv <br />(a) <br />DUE TO, OR AS A CONSEQUENCE OF Interval behveen onset and deal <br />r Ib1 T� � - - -- <br />� Interval between onset' i,iaal1 <br />- DUE TO; UPI SA CONBEOUENCE OR. - _ <br />Icl <br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY IN THE PAST 3 MONTHS? E %AMINER OR❑COROi <br />PART r � /S \( rs 1 n , <br />fj t 1v� <br />(Ages 10541 Yes No Yes No Ves No <br />26a <br />26b DATE OF INJURY (Mo Day. Y,) <br />26, HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />- <br />Swcide Pending <br />26e INJURY AT WORK <br />_ -_� <br />261 PLACE OF INJURY - At home. farm . street factory 21 LOCATION STREET OR R D. NO CITY OR TOWN STA7F <br />❑ <br />ofl•ce bmld, etc lSpecify) <br />Homicide Investigation <br />yes No <br />28a DATE SIGNED (Mr, Day Yr) 28b TIME OF DEATH <br />27a, DATE OF DEATH (Mo. Day. Y0 <br />to s M <br />Day 27c TIME OF DEATH <br />27b DATE SIGNED <br />P y 6 0 J 28c PRONOUNCED DEAD !Mo Day, Yr.I 28d, PRONOUNCED DEAD (Hour, <br />C'Y,I <br />((HMO_ <br />(� <br />M <br />- <br />g —_M <br />27d. To the best of my knowledge. death occur, at the time date and place and due to the ° 28e. On the basis of examination and or investigation, in my opinion dealn occurred at <br />' causelsl stated. j ,.A�� C- \ ,��, ��� 1,.17 }�� - the time, date and place and due to the causels) slated <br />, <br />�` \`1 <br />Title) No <br />) (Si naure and T <br />flel <br />(Signature and Ti Ix <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED' <br />�ES NO F UNKNOWN YES �NO YES �-N0 <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) 'Tvpe or Pont) W �` L� f]�.. •"- (V ` / �Q{ -+A'(� O <br />J�� <br />(� <br />^C. I-E pdti.0 l G S (01.1% <br />, <br />32a. REGISTRAR Ate'„ ♦P +^ <br />32b. DATE FILED BY REGISTRAR (MO. Day vr/ <br />d I Ir )nnn <br />