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200003122 WHEN TENS c.OPY CAA1WS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTE14 R CERTNES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON F_A THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEG - THE LEGAL DEPOSITORY FOR VITAL RECORDS. --.rr - DATE OF ISSUANCE 200001422 FEB 3 1999 LINCOLN, NEBRASKA HEALTH AND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES( A f VITAL STATISTICS_ CERTIFICATE OF DEATH - 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX IMonM "Day Year) Glenn Alber LaBrie jantiary 23, 1999 4. CITY AND STATE OF BIRTH is ncl47 U.S.A.. name Coundryl Sa. AGE - Last Birpvday UNDER t YEAR UNDER 1 DAY 16. DATE OF BIRTH IMonal Day Year) (Yrst Sb. 1 MOS, DAYS 5c. HOURS' MINS. Hastings, Nebraska 81 September 7, 1917 7. SOCIAL SECURTIY NUMBER 88 . PLACE OF DEATH HOSPITALS U Inpatient OTHER; ❑ Nursing Home 504-03-7028 028 ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name /Moot meliry/tlon, g" ~and number) St. Francis Medical Center ❑ DOA ❑ Oft,tspvcv, Be. CITY. TOWN OR LOCATION OF DEATH Sd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island • Yes ® No ❑ I Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATI.ON_ Itd. STREET AND NUMBER /MehdkV lip CydRl8 2 9e. INSIDE CITY L M1TS Nebraska Hall Doniphan 208 W. Bartelt Ave. v Yeses No ❑ 10. RACE - (e.g., White, Black. American hdian. 11. ANCESTRY le.g.. Italian. Mexican. German, etc) t' t2. ® MARRIED ❑ WIDOWED ' 3. NAME OF SPOUSE /n.6. give maiden morel atc.l (Specify( White ISpeciyl J French /Canadian ED NEVER DIVORC ILurye Rader 14a. USUAL OCCUPATION /Gave kindol a+urk done dYNp mast 3 14b. KIND OF BUSINESS INDUSTRY " O 15. EDUCATION (Specify only highest grade connpleted) Eern7A- or Secondary 10 -121 College 11 -4 or 5-1 d wonlnng N/e, even d retired) 18. FATHER -NAME FIRST MIDDLE ST 117 MOTHER FIRST MIDDLE MAIDEN SURNAME 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 193. INFORMANT - NAME (Yes no or unk.) IB yes. give war and dates d serviced 19b. INFORMANT MAILING ADDRESS ;STREET OR R.F.D. NO.. CITY OR OWN. STATE" ZIP( 20.E MER - SIGNATU LI ENO. #722 219. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY -NAME Sunal ❑ Removal rpRetory 2a. F NERAL E - NAME ltd. CEMETERY O CREMATORY LOCATION CITY OR TOWN STATE ❑ Crematbn ❑ DonaUOn 22b. FUNS HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1225 N_ Elm Ave-, Hastings, Nphrap1cp 69901 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)I Imervi�l[�\etween onset and dealn M\ PART) r ► r 1 I O C L r C 1 • 1 'I ( 1 DUE TO, OR AS A CONSEQUENCE OF. Interval between onset and deals I I (b) DUE TO. OR AS A CONSEQUENCE OFD I Interval between onset and Beam I I Ic) OTHER SIGNIFICANT CONDITIONS, C rtolit" GOnllbAng to tee death but not(OMM PARTMIF PEMALE.'NASTHEiftrx 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? If (Ages 10 -54) Yes NO Ves NO Yes D No 26a. 26b. DATE OF INJURY /idol.. Day. Yr1 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident ❑ Undetermined M ' Fl Suicide Suicide Pending 260. INJURY AT WORK 281. PLAe E I INJURY /A lw, larm. street. lactory :k ACE. SPeo 26g. LOCATION STREET OR R.F.D. N0, CITY OR TOWN STATE Homicide Investigation Yea ❑ No ❑ 27a. DATE OFD ATH (Mo.. Day. Ycl 28a. DATE SIGNED /Mo. Day Yr) 28b. TIME OF DEATH S5 ( a 5 `9 1 S�i M 27b. DATE SIG D IMO.. Day. Yr.) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD /Hours rJs M £ M 27d. To Me best d my knowledge. aid occurred at the li to and pac due to the 28e. On the basis of examination and,or investigation, in my opinion death occurred at .- v cause(s) stated. v a the time. date and place and due b the Cause(s) stated. is ignature and Title) nature and Tips 29. DID TOBACCO USE CONTRIBU E DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES F] NO ❑ UNKNOWN ❑ YES �NO ❑ YES IX 1 NO 31, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Prkrll Azariah Kirubakaran M.D. 2116 W. FaWley Ave., Grand Island, NE. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /Mo.. Day. Y,.1 FEB 1 1999 N