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G\ <br />2. SEX <br />3. DATE OF DEATH /Month Day, Year) <br />E. Tucker <br />Female <br />February 25, 2001 <br />�l0 <br />Sit. AGE - Last Birthday I <br />UNDER 1 YEAR <br />T rn > <br />6. DATE OF BIRTH (Month. Day. Year) <br />Yes 0 No <br />Z <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />Sb. MOS DAYS <br />Sc. HOURS' MINS. <br />Warren Arkansas <br />7 <br />CA <br />N_ <br />o <br />Ba. PLACE OF DEATH <br />C) --� <br />HOSPITAL: Inpatient OTHER. Nursing Home <br />x <br />ER Outpatient Residence <br />8b. FACILITY - Name of not msMUlion, give street and number) <br />M # <br />-c M <br />DEAStreet <br />8c. CITY. TOWN OR LOCATION OF TH <br />Bit INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes El No I <br />O <br />-0 <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9C. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (lnc /uding Zip Code/ <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />#20 Chantilly St, 68803 <br />Yes ® No <br />10. RACE - le.g.. White. Black, American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE lilt wile give maiden name/ <br />etc .I ISpec-fyl <br />White <br />(Specify) <br />En lish <br />NEVER DIVORCED <br />M <br />Glen Tucker <br />W <br />lab. KIND OF BUSINESS INDUSTRY <br />75. EDUCATION (Specify only highest grade completed) <br />of working life, even of retired) <br />Homemaker <br />v, <br />r b <br />U1) <br />16. FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />J <br />L. Lucy NMI Outlaw <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />N �D <br />(Yes. no. or unk.) fit yes. give war arid dales d services) <br />30 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />No N/A <br />Glen Tucker <br />191 INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN STATE. ZIP( <br />C) Cn <br />20, EMBAL ER - SK3NAT CENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />�5D - 0/77SP <br />MAR 8 2001 <br />DRA q <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAB <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />OR a 2001 200104104 <br />LINCOLN, NEBRASKA HEALTH AW <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUM <br />VITAL STAT sncs <br />CERTIFICATE OF DF <br />SUPPORT <br />01 02305 <br />1. <br />DECEDENT-NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month Day, Year) <br />E. Tucker <br />Female <br />February 25, 2001 <br />a. CITY AND STATE OF BIRTH ftl rdl n S.A.. name counhy) <br />Sit. AGE - Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year) <br />Yes 0 No <br />(Yrs.) <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />Sb. MOS DAYS <br />Sc. HOURS' MINS. <br />Warren Arkansas <br />7 <br />March 24 1924 <br />7. SOCIAL SECURTIY NUMBER <br />Ba. PLACE OF DEATH <br />HOSPITAL: Inpatient OTHER. Nursing Home <br />26e. INJURY AT WORK <br />ER Outpatient Residence <br />8b. FACILITY - Name of not msMUlion, give street and number) <br />20 Chantill <br />DOA Other(Spec /ty/ <br />DEAStreet <br />8c. CITY. TOWN OR LOCATION OF TH <br />Bit INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes El No I <br />I Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9C. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (lnc /uding Zip Code/ <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />#20 Chantilly St, 68803 <br />Yes ® No <br />10. RACE - le.g.. White. Black, American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE lilt wile give maiden name/ <br />etc .I ISpec-fyl <br />White <br />(Specify) <br />En lish <br />NEVER DIVORCED <br />M <br />Glen Tucker <br />14a. USUAL OCCUPATION /Give kindot work done Owing most <br />lab. KIND OF BUSINESS INDUSTRY <br />75. EDUCATION (Specify only highest grade completed) <br />of working life, even of retired) <br />Homemaker <br />Own Horne <br />Elemen ry or Secontlary 10 -121 College 11 -a or 5• I <br />12ti Grade <br />16. FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />J <br />L. Lucy NMI Outlaw <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />_ <br />19a. INFORMANT - NAME <br />(Yes. no. or unk.) fit yes. give war arid dales d services) <br />30 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />No N/A <br />Glen Tucker <br />191 INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN STATE. ZIP( <br />#20 Chantilly Street Grand Island Nebraska 68803 <br />20, EMBAL ER - SK3NAT CENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />MAR 8 2001 <br />Burial ❑Removal <br />Feb• 27, 2001 <br />Kearney City Cemetery <br />22a. F <br />N RAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE <br />eine Funeral Home <br />El Crema�n ❑ Donal°h <br />Nebraska <br />-Kearney, <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 />IMMEDIATE CCAAUSSE�% (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)I I Interval between onset and death <br />PART I �I1L��t. <br />�• ^�� �• I imervai oetween onset am oeam <br />(b) <br />Lug Ccr� G�f" <br />DUE TO.OR AS A CON NCbOF: - - - -- - - -- - - - - - - - - - - - - - - - - - - - I Interval between onset and death - <br />I <br />' -' <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A <br />1 <br />AUTOPSY <br />WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />11 <br />IN THE PAST 3 MONTHS? <br />%AMINER OR CORONER? <br />(Ages 10 -54) Yes No <br />Yes No <br />Yes 0 No <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />RAccident ❑ Undetermined <br />M <br />0 Suicide ❑ Pending <br />26e. INJURY AT WORK <br />26f. PLACE QFF. INJURY . farm, street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes � No <br />W6ce %AS��e <br />274. DATE OF DEATH (Mo., Day Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yrl <br />28b. TIME OF DEATH <br />ti <br />V Ly W4 O, S aU U, <br />f. <br />. <br />A' z <br />g <br />M <br />Y5 <br />a <br />27 DATE SIGNED /W... Da . .) <br />TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day, Yc) <br />28d. PRONOUNCED DEAD (Hour) <br />$ <br />3 a 0\ <br />M <br />gW� <br />M <br />. To the best of my k e. death r t the time, date and pi ce and due to the <br />28e. On the basis of examination and /or Investigation• in my opinion death occurred at <br />cause(sl sated. <br />° a <br />, the time, date and place and due to the causels) stated. <br />S- nature and T <br />S nature and Title ► <br />DID TOBACCO USE CONTRI HE D H <br />30 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />WAS CONSENT GRANTED? <br />3615 _ \ <br />TKYES n NO El UNKNOWN <br />YES NO <br />YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print/ <br />I <br />1 Daniel P_ T4arr;;hill F MD, nQ4 TnHian Street, St- Paill - Nebraska 68R:73 <br />i 32a. REGISTRAR of <br />32b. DATE FILED BY REGISTRAR /Mo.. Day. Yr) <br />i <br />MAR 8 2001 <br />J" 0 // U__ <br />L.EGA l Da sc e:i P-rz60 <br />