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Y- n = D Z ^ 5 Q YN1i `� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAhM SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OM" THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALfflAy m THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 2''0008105-1 ' MAR 82000 V ^kS LINCOLN, NEBRASKA HkALINM -D14t STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMWSxk vrrAL STATISTICS CERTIFICATE OF DEATH �'Ys�-l�!bPEl7 j rF,*q*1*AR' vicES�YSi°�M' n cn M O T � Z z rn D M r � r D a3 CD CD © N N o N O o � o W 14. ►--a O CA - 1 DECEDENT - NAME FIRST MIDDLE LAST -2 ,SEX - 3. DA FE OF DEATH /Month. Day. Year/ Steven Raymond Amack C7 ZD rn$ ;9 O -T1 co f v \J MOS DAYS rn M z ZB IYrs.) Sb. 44 May 4, 1955 t.. Be PLACE OF DEATH 505 -78 -1747 /V 6b FACILITY - Name to wt,nstitution. give sheet and number) GO SAN SERVICES MOW-MFILE WITH gSLC *416H IS �'Ys�-l�!bPEl7 j rF,*q*1*AR' vicES�YSi°�M' n cn M O T � Z z rn D M r � r D a3 CD CD © N N o N O o � o W 14. ►--a O CA - 1 DECEDENT - NAME FIRST MIDDLE LAST -2 ,SEX - 3. DA FE OF DEATH /Month. Day. Year/ Steven Raymond Amack Male' January 13 2000 I. CITY AND STATE OF BIRTH pl not n USA.. name counayl Sa. AGE - Last Birthday I UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (Monts. Day. Year) MOS DAYS 5c. HOURS WIN Superior, Nebraska IYrs.) Sb. 44 May 4, 1955 7. SOCIAL SECURITY NUMBER Be PLACE OF DEATH 505 -78 -1747 HOSPITAL Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 6b FACILITY - Name to wt,nstitution. give sheet and number) BryanLGH Medical Center West ❑ ODA ❑ Other t$pecdy, Bc. CITY TOWN OR LOCATION OF DEATH I Bd INSIDE CITY LIMITS 8e COUNTY OF DEATH Lincoln i Yes ® No ❑ Lancaster this RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER tlncludmg Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 2315 Gateway Ave.68803 Ye9 Q No 10. RACE - (e.g., White. Black. American Indian 11. ANCESTRY le. g.. Italian, Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (II wAe give maiden name) I ( c'y1 ihte fSOecuM American NEVER DIVORCED M 1 Friday Frin er 148 USUAL OCCUPATION tGwe kind of w rk done during most tab KIND OF BUSINESS INDUSTRY 15 EDUCATION (Speedy only highest grade completed) of wwkmg tile. Bven rt reeredl Elementary or Secondary 10 -121 College .1 4 or 5- Service Tech. Man Fast Food 12 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Raymond Amack Wanda Anderson 18. WAS DECEASED EVER IN U.S. ARMED FORCES' 19a INFORMANT - NAME (Yes no or unk.) III yes give war and dalas of seniicesi No Friday Amack I _ 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN. STATE, ZIP) 2315 Gateway Ave., Grand Island, Nebraska 68803 20 EMBALME -SIGN LIRE 8 L NSE NO 21a METHOD OF DISPOSITION lib. DATE 21c. CEMETERY OR CREMATORY NAME ttll(Z 1 ❑Burial ❑Removal Jan. 17, 2000 Central Nebraska Cremator 718. FUNERAL HOME NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑ Cremation El Donation Kleine Funeral Home Gibbon Nebraska 22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 3213 W. North Front St. , Grand Island Nebraska 688 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib), AND (c)) 1 Interval between onset and death PART � 1 I Me.N i I a I ty I DUE TO, OR AS A CONSEOUEN F- Interval between onset and death I Of DUE TO. OR AS A CONShuUENCE OF Interval between onset and death I ' I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART If IF FEMALE. WAS THERE A 124 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PREGNANCY n IN THE PAST 3 MONTHS, EXAMINER OR CORONER' (Ages 10 -54) Yes No Yes No Yes R No 26a 25b. DATE OFINJURY tMo. OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED A- chant Undetermined 776Un M Suicide Pending 26e. INJURY AT WORK 26f. PLACE OF INJURY " 't home, farm. street. factory office building, etc tSpeoily) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation ❑❑ Yes No 27a DATE OF DEATH (MO.. Day. Yrl 28a. DATE SIGNED tMo.. Day Yr.) 28b TIME OF DEATH i 27b. DATE SIGNED tMo.. Day Yr1 27c. TIME OF DEATH 28c PRONOUNCED DEAD tMo.. Day, Yr.) 28d. PRONOUNCED DEAD /Hour) d a 65 65 M 27d TO the best of my knowledge the time ate plate and due to the 28e. On the basis of examination and or investigation, in my opinion death occurred at ,r ° a causelsl slated. C the time, date and place and due to the cause(s) stated. Signature and Title) ► (Signature and Title DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAf4 OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' 129 ❑ YES NO ❑ UNKNOWN ITV YES ❑ NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prinp TDalj � A L. , 5�.% -t1. N.c� aG 31 S, �o 32a REGISTRAR i 32b. DATE FILED BY REGIS � � Qey� I OQ Lot Thirteen (13), in Block Three (3), in Le Heights Second Subdivision, in the city of Grand Island, Hall County, Nebraska An The Easterly Ten (10) feet of Lot Two (2) and the west Fifty-Eight (58) feet of lot Three (3), Block Two �I