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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Harold Robert Klein <br />2 SEX <br />Male ' <br />3 DATE OF DEATH !Month. Day. Year) <br />December 1, 2001 <br />l 4. CITY AND STATE OF BIRTH Of not it; USA.. name country) <br />Grand Island, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />74 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day Year) <br />Ocfoher 27, 1927 <br />55 MOS. 1 DAYS <br />5c. HOURS MINS- <br />7. SOCIAL SECURTIY NUMBER <br />506 -22 -4088 <br />8a. PLACE OF DEATH <br />HOSPITAL. Inpatient OTHER. X Nursing Home <br />__. _. <br />_0? -Name /Ifeof insfi(ution, give street and number) <br />3everl Healthcare Lakeview <br />ER Outpatient Residence <br />II DOA Other /Spec tyr <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />n <br />Yes L I No ,r <br />8c CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />80 NSIDE MY LIMITS <br />Yes [ <br />Be COUNTY OF DEATH <br />Hall <br />RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Isl____- <br />90. STREET AND NUMBER (Including Zip Code) <br />1405 Hwy 34 W, 68801 <br />9e. INSIDE CITY LIMITS <br />Yes` No ❑ <br />10. RACE - (e.g., White. Black American Indian. <br />etc.) (Soec,lyl M <br />White <br />11. ANCESTRY leg.. Italian. Mexican. German, etc) <br />ISpec�ty) <br />American <br />12. ra MARRIED ❑ WIDOWED <br />NEVER DIVORCED <br />MARRIED <br />13 NAME OF SPOUSE ill wile . give maiden name) <br />Marjorie Humpal <br />14a. USUAL OCCUPATION (Gwe kind of work done during most 14b. KIND OF BUSINESS INDUSTRY <br />of working f i f e , even rf retired! <br />Technical Service Representa�ive Retail <br />15 EDUCATION (Specify only highest grade completed) <br />E e Lary Secdn 8).121 College It -4 or 5.1 <br />1I rac ry e <br />20. EMBALMER - SIGNATURE 8 LICENSE NO <br />. �., r f <br />,, <br />(U11i � 4j� <br />21a METHOD OF DISPOSITION 1215 <br />Bonet no ,„„, <br />DATE <br />Dec. 4, 2001 <br />21c. CEMETERY OR CREMATORY - NAME <br />Grand Island City Cemetery <br />■ Cremation ❑ Dora,,,, <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />1 Grand Island, Nebrask <br />22 FUNERAL HOME . NAME <br />Kleine Funeral Home <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) <br />3213 W. North Front Street, Grand Island, Nebraska 68803 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (411 I Interval between onset and death <br />PART <br />/� <br />Ial - <br />DUE�0. OR AS A CONSEQUENCE OF. <br />(/' I Interval between onset and death <br />05 fir^ - �i� - ,% . ,�" T { <br />DUE TO OR AS A CONSEQUE Interval between onset and cleat» <br />OF <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />8 <br />PART 111 IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS <br />(Ages 10 54) Yes -1 No C <br />24. AUTOPSY <br />n <br />Yes I I No <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />n <br />Yes L I No ,r <br />26a. <br />■ Accident Undetermined <br />. Suicide ■ Pending <br />111 Homicide Investigation <br />265 DATE OF INJURY (Mo.. Day Yr.) <br />26c. HOUR OF INJURY <br />M <br />26cl DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes 1111 No ❑ <br />261 PLACE butOF. INJURY - (SP q,4t home. farm. street. factory <br />office dmg. etc. eC iN1 <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />27a. DATE OF DEATH (Mo.. pay Yr) <br />/ l / /J / / J I <br />28a. DATE SIGNED (Mo.. Day. YrI <br />286. TIME OF DEATH <br />28c. PRONOUNCED DEAD (MO. Day. Yr) <br />28d. PRONOUNCED DEAD (Hour) <br />27b. DATE SIGNED' (Mo.. Day Yr) <br />/ 'Z.., - <br />27c. TIME OF DEATH ��// <br />) r A V. <br />28e. On the basis of examination anchor investigation, in my opinion death occurred at <br />the time. date and place and due to the cause(s stated. <br />r (Signature and Title( Or <br />270. To the best of my know' dge. dea occurred at t time. date and place d due to the <br />cause(sl stated. � �J <br />r (Signature and Title) ► -. 7 (/ <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEA ? <br />YES NO UNKNOWN' <br />30.a AS ORGAN OR TISSUE DONATION BEEN CONSIDERED <br />YES ;L <br />30 b WAS CONSENT GRANTED <br />YES \LfT NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( 1 7ype or Print) <br />Gordon J. Hrnicek MD, 729 N. Custer, Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />I LM t <br />325 . DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />DEC 1 0 2001 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN- SERVICES FINANCE AN WSUPPORT <br />VITAL STATISTICS 0 1_ l 13678 <br />H <br />CERTIFICATE OF DEAT <br />WHEN THIS COPYCARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERWCES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDON'FfiX WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION,WI4IG H IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ( 201607834 <br />DEC 11 2001 .StANLEYS._COOPER <br />ASSISTANT STA rE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND #/UMANSERWCESSYST€M <br />16. FATHER - NAME <br />FIRST <br />MIDDLE <br />Samuel NMI Klein <br />18. WAS DECEASED EVER IN U. S. ARMED FORCES? WWII <br />np. or unk.) III yes 9w war and dales of services) WYY I I <br />Yes 1 07/30/1946 <br />LAST <br />17 MOTHER <br />19a. INFORMANT - NAME <br />Marjorie Klein <br />19b. INFORMANT MAILING ADDRESS (STREET OR R .D NO CITY OR TOWN. STATE ZIP( <br />1804 S. Blaine, Grand Island, Nebraska 68803 <br />FIRST <br />MIDDLE <br />Lillian NMI Ka <br />MAIDEN SURNAME <br />