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Rev 11,97_ z W 0 W U W 0 LL O W a z C7 th STp *' I ASKA- DEPARTMENT OF HEALTH AND HUMAN f 1-1 IC NANCE AND S 100015 34 VITAL STATISTICS CERTIFICATE OF DEATH I DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3 DATE OF DEAT(FiMgntnllA) Veal Robert Lafe Campbell Male iJanuary\\ll((1JJ44,a2000 (Ages 10.54) Yes No 4 CITY AND STATE OF BIRTH /anal n USA. name country/ Sa AGE - Last Birthday UNDER 1 YEAR UNDER i DAY 6. DATE OF BIRTH ,Mona+. Oak Veal) - Grand Island, Nebraska (Y's) 85 5b. MOS I DAYS 5c. HOURS' MINS August 23, 19_14 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 505 -22 -9517 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home _- - - -- 1:1 ER Outpatient __ ® Residence 8b FACI( ITV - Name tit not,nshfutlon, give street and numbed 247 S. Locust St. ❑ DOA ❑ Other tSce(41 8, CITY TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yea ® No ❑ Hall 9. RESIDENCE STATE 9b COUNTY 9c CITY, TOWN OR LOCATION 9d. STREET AND NUMBER 0naudry Zp Code) 9e INSIDE CIT, 26d. PRONOUNCED DEAD 4 am M Nebraska Hall Grand Island 247 S. Locust St. 6880 Yes ® N, E G"r., . data and place and d to the us 10 RACE leg. While. Blank. American Indian. 11. ANCESTRY (eg. Italian. Mexican. German, etc) 12. ❑ MARRIED ® WIDOWED NAME OF SPOUSE !„ wrle q,ve ma Men name! 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH, etc I ISoecdy) White ISMcity) American NEVER DIVORCED 113 Helen Fox (Dec) ❑ YES IC�.-1 NO ❑ YES © NO MR, t K Cole GIPD 131 S Locust Grand Island NF 68801 140 USUAL OCCUPATION IGrve krod M work done during most 74b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) - of —Amq Me, even d reared/ Grocer /Meat Cutter Retail Grocer Sales - -- Ete a tar or dory 0 -t21 College i+ s u• i�tyh grade 16 FATHER - NAME FIRST MIDDLE LAST _ MOTHER FIRST MIDDLE MAIDEN SURNAME III Lafe F. Campbell Jessie Whitehead 18 WAS DECEASED EVER IN U.S ARMED FORCES? _ tga INFORMANT NAME (yes rip. or unk.) lit yes give war and dales of services) No -- - - - - -- I Marjorie A. Fox - Niece _ 19b INFORMANT MAILING ADDRESS ISTRFET OR RF D NO. CITY OR TOWN. STATE. ZIP) 6534 S.W. 23rd CT., Topeka, Kansas 66614 20 E M - SIGNAT UCE NO 21a METHOD OF DISPOSITION 21b. DATE CEMETERY ORCREMATORY NAME 121c Burial ❑Removal Jan. 17 2000 Westlawn Memorial Park 22a FUNERAL HOME. - E _- - lid CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livin ston- Sonderl n F.H. ❑cremalon ❑Donakon Grand Island Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO C17 OR TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <J i MCUiN t [ I.nUJC Inx i cn Vrvlr VrvC IJ,UJC �Cn LuvC rVn iar IOF nnU Io11 � �,merv.w rrenween nnsei n ,. .TART ! Cardiopulmonary failure unknown __ DUE TO, OR AS A CONSEQUENCE OF Inte,al between oils.. e•..• IN DUE TO OR AS A between oosef a•i,i +.•. r• Icl OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS, I 24 AUTOPSY -t-- 4 _ 125 WAS CASE REFERRED lO ME DWAI OR CORONF R' 11 (Ages 10.54) Yes No Yes No eXAMINFR Yes Nn �- 26a 26b DATE OF INJURY (Mo.. Day. Vtl 26c HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED Accident F] Undetermined M Su ,de Pending Homicide Investigation 26e. INJURY AT WORK Yes No ❑ ❑ 261 PLACE QF INJURY - At hog, farm, street. faclory o ice buikting, etc (Speary) 269 LOCATION STREET OR R D. NO. Ci I I, OR TOWN 6;A;,, 27a DATE OF DEATH (Mo Day. Vcl FINE SIGNED (Mo Day YO 2Bp TIME OF DEATH f o un d Y 276 DATE SIGNED (Mo Day. Vr I 27c TIME OF DEATH M L CL' a io 28c 0MINOUNCIEdDEAK /AM Day, Vrl 26d. PRONOUNCED DEAD 4 am M 27d To the best of my knowledge death ocruned at the time, date and place and due to the 28e. On the basis d exammalnn and or investigation. in ngi neon 09 In orcuMed at R causelsl staled. r.+ a G"r., . data and place and d to the us ISi nature and Title / nat and Title r 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH, 3o a NAS ORGAN OR TISSUE DONATION BEEN CONSIDERED, WAS CCiN6 tN GRANTED7 .)r ❑ YES ❑ NO � UNKNOWN ❑ YES IC�.-1 NO ❑ YES © NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type m Prrnll r t K Cole GIPD 131 S Locust Grand Island NF 68801 32a REGISTRAR _ 32b DATE FILED BY REGISTRAR IMO. Day Vr l FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ............................... . C ................................ D ................................ E ......... ....................... Part II .................. .. ..TMV.......................... NSC.................................................................................................................................................................................................................... ............................... Census Tract No. Work..................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Rdject............ ._ ..... ....... . ............. _ _ .................... .......-.... _ .............. .................................................................................................................. ID Printed with soy Ink on recycled paper I hereby certify this to be a true and correct copy of the original filed with the State of Nabraska by Signed in my presen �_ of Notary Public w2cm