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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MMA"ERVICES
<br />SYSTEX IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE60k CTIIIFIl5.WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST) T $EBTLDA¢.WHI&H I
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 8 =
<br />2 0 0 0 0 4 6 AT11E�1fbdPt
<br />JUN 12 2000 ASSIST,j�11TlTAiEREG/STRt-
<br />LINCOLN, NEBRASKA HEALTH AND HUI&N &I W- 100 TEII
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkLiKR& RNANt-t AND SUiq-'ORT
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH
<br />)�Ni NAME FIRST MIDDLE LAST 2 SEX , 3 DATE OP DEATH rMl If L.rl ear
<br />Richard Little Brown Male May 25, 2000
<br />f`.i 1 v AND STATE OF BIRTH Ill riot ur US4 name country)
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6 DATE OF BIRTH ,Month Dap ✓earl
<br />Altoona, Pennsylvania
<br />IY's
<br />70
<br />Sb MOS DAVS
<br />SC HOUR$ MINS
<br />5, 1929-
<br />Q�
<br />_September
<br />8a PLACE OF DEATH
<br />176 -24 -3087
<br />C
<br />rn �
<br />St. Francis Medical Center
<br />CD `_�
<br />C) Cn
<br />o
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />1 Yes [�] No ❑
<br />Hall
<br />9a RESIDENCE STATE 9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER ilnUUd,,g Z,p Code) 9e INSIDE CITY LIMITS
<br />Nebraska i Hall
<br />0 __q
<br />1720 S. Curtis 68803 Yes Nn ❑
<br />10 RACE fe.g.. Whue. Black Amenoan Indian
<br />it ANCESTRY 1e_q Italian. Mexican. German. elcl
<br />12 O MARRIED F-] WIDOWED
<br />' 3 NAME OF SPOUSE dl wde q maiden name;
<br />etc I ISoecityl
<br />White
<br />ISDeary1
<br />NEVER DIVORCED
<br />❑ MARRIED
<br />Kris Nolan Clare
<br />_ _American
<br />14a ''tSUAL OCCUPATION IG— kind or work done during most
<br />141, KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION Specify only highest grade completed)
<br />at working Me. even ,I refired,
<br />Owner /Operator
<br />Travel Agency
<br />=
<br />cn
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />,^
<br />z
<br />rn
<br />O
<br />ft}e time date and place the Sausel sl st led t � -
<br />Y 1 f
<br />Si nature and Tnlel Y i – {y_A ,Y 7
<br />!mi
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED"
<br />30.b W(, ONSENT GRANTED'
<br />(DEATH'
<br />❑ YES ❑ NO I.- UNKNOWN
<br />rn
<br />X ❑ YES ® NO
<br />IT NAMEATJD ADDRESS OF CERTIFIER iPHY�SIIcCIIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (type or Pnnl/
<br />Ellen L. Totzke 117 E 1 t ST. Grand Island ,Nebraska 68801
<br />co
<br />32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.)
<br />- - - - 4467_
<br />JUN 6 2000
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MMA"ERVICES
<br />SYSTEX IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE60k CTIIIFIl5.WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST) T $EBTLDA¢.WHI&H I
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 8 =
<br />2 0 0 0 0 4 6 AT11E�1fbdPt
<br />JUN 12 2000 ASSIST,j�11TlTAiEREG/STRt-
<br />LINCOLN, NEBRASKA HEALTH AND HUI&N &I W- 100 TEII
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkLiKR& RNANt-t AND SUiq-'ORT
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH
<br />)�Ni NAME FIRST MIDDLE LAST 2 SEX , 3 DATE OP DEATH rMl If L.rl ear
<br />Richard Little Brown Male May 25, 2000
<br />f`.i 1 v AND STATE OF BIRTH Ill riot ur US4 name country)
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6 DATE OF BIRTH ,Month Dap ✓earl
<br />Altoona, Pennsylvania
<br />IY's
<br />70
<br />Sb MOS DAVS
<br />SC HOUR$ MINS
<br />5, 1929-
<br />_
<br />' SOCIAL SECURTIY NUMBER
<br />_September
<br />8a PLACE OF DEATH
<br />176 -24 -3087
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nirsing Home
<br />-
<br />© ER Outpatient ❑ Res•.dence
<br />8b FACILITY - Name 111 nor rnstlruGon. give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Othe,iSper Ayi
<br />BC 'IT, TOWN OR LOCATION OF DFATH
<br />18d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />1 Yes [�] No ❑
<br />Hall
<br />9a RESIDENCE STATE 9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER ilnUUd,,g Z,p Code) 9e INSIDE CITY LIMITS
<br />Nebraska i Hall
<br />Grand Island
<br />1720 S. Curtis 68803 Yes Nn ❑
<br />10 RACE fe.g.. Whue. Black Amenoan Indian
<br />it ANCESTRY 1e_q Italian. Mexican. German. elcl
<br />12 O MARRIED F-] WIDOWED
<br />' 3 NAME OF SPOUSE dl wde q maiden name;
<br />etc I ISoecityl
<br />White
<br />ISDeary1
<br />NEVER DIVORCED
<br />❑ MARRIED
<br />Kris Nolan Clare
<br />_ _American
<br />14a ''tSUAL OCCUPATION IG— kind or work done during most
<br />141, KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION Specify only highest grade completed)
<br />at working Me. even ,I refired,
<br />Owner /Operator
<br />Travel Agency
<br />_
<br />Elementary prsecpndarY 012) 4 Yeartsr
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />�17
<br />Carl W. Brown
<br />Margaret Little
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<br />IH fi ,, ULI,LAhcU LVLH IN UJ AHMtU Iuo I—UHMANI NAME
<br />YNs no >r inkI III yes qv. war and `tales of services) !
<br />No L -- - - - - -- Kris Nolan Brown
<br />It, INFORMANT MAILING ADDRESS ISTRFFT OR R F D NO CITY OP TOWN S � ATE. ZIP'
<br />1720 S. Curtiss Grand Island NE 68803 _
<br />Ban
<br />20 E LM R-SIGNA E&�SrO ���� 2111 T. OF DISPOSITION nib. DATE 21c CEMETERYORCHEMAT VHY NAME
<br />al Removal i May 30, 2000 Westlawn Memorial Park
<br />22a FUNERAL HOW,- - NAME C001 1 21 d CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />Livingston- Sondermann F.H. ❑Crematron ❑Donakpn I Grand Island, Nebraska
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />STATE _ --
<br />_ 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR jai !b). AND (C)I yyy Interval between onsel and 1-1r,
<br />PART o '
<br />Ialcardivulmonary fai1iira 1
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />I
<br />N
<br />DUE 10. OR AS A CONSEQUENCE OF
<br />CI
<br />Interval between onset ano deal"
<br />Interval between onset ano dealt
<br />OTHER SIGNIFICANT CONDITION$ - Cond NO'S conlobtiong to the death
<br />RT III IF FEMALE WAS THERE A
<br />2n AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />j PART
<br />PREGNANCY IN THE PAST 3 MONTHS'
<br />Ix,
<br />EXAMINER OR CORONER'
<br />(Ayes 1G -ial Yes No
<br />Yes No
<br />Li
<br />Yes No
<br />-„r 250 DATE OF INJURY IMO Day. YrJ 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED
<br />cc,nenl J Undelennmed
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<br />cde i� Pentlinq 16e IN,;URYAT'NORK 1261 PLACE OF INJURY- At home la— slrael factory 26g I.O ITA ONC STREETOR RFD NO CITY OR TOWN 'yTAt'.
<br />_ ❑ ❑ office building. etc iSpecdy/
<br />t,.nc,de
<br />.nvesogauo^ ves No
<br />21, DATE OF DEATH IMO Day Yr 1
<br />28a DATE SIGNED (Mo.. Day Yc)
<br />28b TIME OF DEATH
<br />n-
<br />>' �'
<br />6 12 /2000 _
<br />28c PRONOUNCED DEAD lMo Day. YU
<br />9420 AM M
<br />28d. PRONOUNCED DEAD (HOUu
<br />w N 27b DATE SIGNED (Mo Dap Yr,
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<br />27c. TIME OF DEATH
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<br />27d Tu the best of my knowledge oeaah orr ieA at the time date and place and due 10 the
<br />28e On the basis of examination and or, nvesligdlipn. in my opinion death o curved al
<br />Cdusel,l sailed
<br />III gnature and Title) ►
<br />ft}e time date and place the Sausel sl st led t � -
<br />Y 1 f
<br />Si nature and Tnlel Y i – {y_A ,Y 7
<br />2q DID TOBACCO USE CONTRIBUTF TO THE
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED"
<br />30.b W(, ONSENT GRANTED'
<br />(DEATH'
<br />❑ YES ❑ NO I.- UNKNOWN
<br />t' ❑ YES © NO
<br />X ❑ YES ® NO
<br />IT NAMEATJD ADDRESS OF CERTIFIER iPHY�SIIcCIIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (type or Pnnl/
<br />Ellen L. Totzke 117 E 1 t ST. Grand Island ,Nebraska 68801
<br />32a REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.)
<br />- - - - 4467_
<br />JUN 6 2000
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