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;k � 11 r' e L 37 SIAM OF NDI SlU MARIMENT OF IMAXM AND M MM SMVK'ES 2 u Q O�T� 4 294135 VITAL STATI M CERTFRCATF OF "PATH t DECEDENT -NAME FIRST MIDDLE LAST M 3 DATE OF DEATH /Moen Day Yarl Carl Wallace Davis Jr. Male March 21, 2000 So AGE - Last daY UNDER 1 YEAR _n i g S. DATE OF BIRTH Adwelt. pay Yee" Sb MOS. DAYS 1 k. HOURS RAINS C3 c) Cn (YM-I n nC: 77 n i A t 13 1922 ° n c N o 510 -16 -6710 MOSPITILL R kv4m"ra OTHER ❑ Nurso g Home ❑ ER OUpaaare ❑ Resdence x Clarkson Hospital � �� m Sc CIT- TOWN OR LOCATION OF DEATH CD n �.1 Omaha Ya 13 ❑ Douglas I m 9a RESIDENCE - STATE _G O CL 7C Nebraska Hall �Grand Island o N p CD vi 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /d wk. gne made" rwnel at �SOealYl White ISPadayl I American YT F—► T1 O KIND OF BUSINESS INDUSTRY 15. EDUCATION ISPSCIIY or" htgnee grace ctlntplaso) d aakmg h* ever d r@~1 ineer Leon Plastic Elementary or Secondary 10 -121 CONgt I1 -e a 5- I 4 M 16. FATHER - NAME FIRST MIDDLE LAST = m O c Hazel F. Proctor 16 WAS DECEASED EVER IN U.S. ARMED FORCES? Q o i es WWII -7 1 44 to 6/8/46 Janet Davis 19b INFORMANT MAILING ADDRESS (STREET OR RF.0 NO.. CRY OR TORN. STATE. DPI 4217 New York Avenue Grand Island Nebraska 68803 Cn F—a Cl) Not ErmbaLned ❑ a.xd ❑ y Kar. 22 2000 1 Elmore CregiatgKy . FUNERAL HOME - NAME 21d. CEWTERY OR CREMATORY LOCATION CITY OR TOWN STATE fel- Butler- Geddes F. He ® Genfaon ❑ Do. Omaha Nebraska 22b FUNERAL HOME ADDRESS (STREET OR RF.O, NO.. CRY OR TOWN. STATE DPI 1123 West Second Street Grand Island Nebraska 68801 -5899 23 �MMEDIATE CAUSE PART qukctYA0Lk cQl (ENTER ONLY ONE CAUSE PER LINE FOR (a1, MI. AND (cll w al between omel and seam Ukrci no�A 0 5' MoNJ11..Jn �'r10S co DUE TO. OR AS A CONSEQUENCE OF Irlmal betwee, anal and 0ea" (bl DUE TO. OR AS A CONSEQUENCE OF InWval between anal and deem Cn Ic) PART OTHER SIGNIFICANT CONDITIONS - Ca (tone cw*ibm�rg to Ina dent but not mieao PART al IF FEMALE. WAS THERE A 2e AUTOPSY 25 WAS CASE REFERRED TO MEDICAL N PREGNANCY N THE PAST 3 MONTHS( ___j N ..0 (Agee 10-5+) Y« No 11 Yes No Yes No 261. 26b. DATE OF INJURY (Ada. lay. Yr-/ 26c HOUR OF INJURY tad. DESCRIBE HOW INJURY OCCURRED rA Acc wv UrtWM W nnkn SIAM OF NDI SlU MARIMENT OF IMAXM AND M MM SMVK'ES 2 u Q O�T� 4 294135 VITAL STATI M CERTFRCATF OF "PATH .; r f, Nt. This this d4olt;senC tto be a true copy of an original record on file with Vital statistics"' shlos County xpentfi .Department, Omaha, Nebraska, Certified copies must have a raised seal th e A&Ac She left. Reproductions of this green certificate are not legal copies.'., "d M Date issuek. Registrar: � Lot Eight (8) , in Block Two (2) , Capital Heights Second Subdivision to the City of Grand Island Hall County, Nebraska, as surveyed, platted and recorded. ' t L t DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH /Moen Day Yarl Carl Wallace Davis Jr. Male March 21, 2000 �. GTY AND STATE OF BIRTH Al not an U S.A. name oealay/ So AGE - Last daY UNDER 1 YEAR UNDER I DAY S. DATE OF BIRTH Adwelt. pay Yee" Sb MOS. DAYS 1 k. HOURS RAINS Kansas City, (YM-I Kansas 77 A t 13 1922 7 SOCIAL SECURTIY NUMBER W PLACE OF DEATH 510 -16 -6710 MOSPITILL R kv4m"ra OTHER ❑ Nurso g Home ❑ ER OUpaaare ❑ Resdence 9D FACILITY Name (e ndf rnOSMIGn, 9" S&M and M~) Clarkson Hospital ❑ DOA ❑ Olher tSaec,n, Sc CIT- TOWN OR LOCATION OF DEATH 6o INSIDE CRY LIMITS Be COUNTY OF DEATH f Omaha Ya 13 ❑ Douglas I 9a RESIDENCE - STATE 9b COUNTY CRY. TOWN OR LOCATION 9o. TREET AND NUMBER /nc1.dny AP Code/ 9e INSIDE CRY LIMITS Nebraska Hall �Grand Island 4217 New York Ave. 68803 Y« ®^o ❑ 10 RACE - (e.g.. YAM Black Amencan iW.w 11. ANCESTRY le q.. Gale n. Me.tcant. Gemmel- ski 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /d wk. gne made" rwnel at �SOealYl White ISPadayl I American NEVER VORCED DI Janet Wiseman tea USUAL OCCUPATION /Give kladol wok done dwi g met teb. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISPSCIIY or" htgnee grace ctlntplaso) d aakmg h* ever d r@~1 ineer Leon Plastic Elementary or Secondary 10 -121 CONgt I1 -e a 5- I 4 16. FATHER - NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Carl We Davis Sr. Hazel F. Proctor 16 WAS DECEASED EVER IN U.S. ARMED FORCES? 1ge. INFORMANT -NAME Ia. ro. a unk.) IN yes. give war no dazes of servic" i es WWII -7 1 44 to 6/8/46 Janet Davis 19b INFORMANT MAILING ADDRESS (STREET OR RF.0 NO.. CRY OR TORN. STATE. DPI 4217 New York Avenue Grand Island Nebraska 68803 20 EMBALMER - SIGNATURE 6 LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME Not ErmbaLned ❑ a.xd ❑ y Kar. 22 2000 1 Elmore CregiatgKy . FUNERAL HOME - NAME 21d. CEWTERY OR CREMATORY LOCATION CITY OR TOWN STATE fel- Butler- Geddes F. He ® Genfaon ❑ Do. Omaha Nebraska 22b FUNERAL HOME ADDRESS (STREET OR RF.O, NO.. CRY OR TOWN. STATE DPI 1123 West Second Street Grand Island Nebraska 68801 -5899 23 �MMEDIATE CAUSE PART qukctYA0Lk cQl (ENTER ONLY ONE CAUSE PER LINE FOR (a1, MI. AND (cll w al between omel and seam Ukrci no�A 0 5' MoNJ11..Jn �'r10S DUE TO. OR AS A CONSEQUENCE OF Irlmal betwee, anal and 0ea" (bl DUE TO. OR AS A CONSEQUENCE OF InWval between anal and deem Ic) PART OTHER SIGNIFICANT CONDITIONS - Ca (tone cw*ibm�rg to Ina dent but not mieao PART al IF FEMALE. WAS THERE A 2e AUTOPSY 25 WAS CASE REFERRED TO MEDICAL N PREGNANCY N THE PAST 3 MONTHS( EXAMINER OR CORONER' (Agee 10-5+) Y« No 11 Yes No Yes No 261. 26b. DATE OF INJURY (Ada. lay. Yr-/ 26c HOUR OF INJURY tad. DESCRIBE HOW INJURY OCCURRED Acc wv UrtWM W nnkn M ❑ Su cde Pending 26e. INJURY AT WORK 261. PLACE OF MUD ldr , farm, weal hctory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homcde Wesogabon Yes ❑ No 1-1 dflea ba1W1g, (l 27a DATE OF DEATH /t.. Day Yr./ 286 DATE SIGNED (W Day Yr I 2eb TIME OF DEATH March 21 2000 a M 211 DATES PNEEDD /1M1 Day Yr) 727cT*AEOF DEATH 2✓!c. PRONOUNCED DEAD /Mo. Day. Yr/ 2Bd. PRONOUNCED DEAD rSTi :15 A. M a 8 M a 27c To ae bal of my knowledge, dean ocnneo a le Men. dale and due 10 ae 211a On ae Was a exanemaon and a eMYgaarm. n salt oCdumW al a a causes) sled. a ae Men. oee and place and case bate Causels) 11911116d. I nalwe and Tool 0 l— `- �'�`�" ` i e and T.1181 29 DID TOBACCO USE CONTRIBUTE TO THE, DEATH? 30a 4 'F• HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' YES ❑ NO " IJ f�l�l.'? I;- I K YES ❑ No . s 111"""'-' "' ❑ YES C9 NO � �y�� 31 NAME AND ADDRESS OF CF,WF YSIGIAIN ER -S '1 j,Ll ATTORNEY( 1Typea,,Prap 4-A41 32, REGISTRAR - 's6V,y. _. 32b DATE FILED BY REGISTRAR (Ato Day �•a' a (YJ/� MAR Ar LeAYa2 .; r f, Nt. This this d4olt;senC tto be a true copy of an original record on file with Vital statistics"' shlos County xpentfi .Department, Omaha, Nebraska, Certified copies must have a raised seal th e A&Ac She left. Reproductions of this green certificate are not legal copies.'., "d M Date issuek. Registrar: � Lot Eight (8) , in Block Two (2) , Capital Heights Second Subdivision to the City of Grand Island Hall County, Nebraska, as surveyed, platted and recorded. ' t L