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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN
<br />SYSTE14 R CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL 09
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIIS7,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AUG 42000 200105106 =,
<br />AS$1S1'i
<br />LINCOLN, NEBRASKA HEALTH AND NUMA-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFJ6
<br />VITAL STATISTICS
<br />CRRTTFTCATF. OF DEATH,
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<br />DF`'EDENT NAME FIR$'
<br />MIDDLE LAST
<br />2 SEX
<br />App /Alonln Dat. 1'ear
<br />Clinton
<br />�a
<br />Dale
<br />Male
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<br />CITY AND STATE OF BIRTH ecountryi
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tat. (b). AND (c)) Interval between onset and death
<br />Sa AGE - Last BiM hd.y
<br />UNDER I YEAR
<br />UNDER I DAV
<br />6 DATE OF BIRTOH'
<br />v v—I
<br />5b MOS DAYS
<br />5c. HOURS MINS
<br />III IF FEMALE. WAS THERE A
<br />2a AUTOPSY
<br />IV's I
<br />PART PREGNANCY
<br />Grand Island, Nebraska___
<br />'77
<br />DiIabete_ s CAD PVD COPD
<br />(Ages 10-541 Yes —
<br />Ma 1 , 1923
<br />7 SOCIAL SECURTIY NUMBER
<br />26a 126b DATE OF INJURY /MO. Day. Yr.)
<br />Ba PLACE OF DEATH
<br />HOSPITAL � Inpatient OTHER � Nursinq H,tmr
<br />505 16 0058
<br />A,--, LJ Undetermined
<br />_. _ -_
<br />E] ER Outpatient Residence
<br />8b FACILITY tit nol,nstifufion, give street and number)
<br />7�7NTa�me (r
<br />1 Vt. 1Y yy IHCS
<br />r
<br />26q LOCATION STREET OR R F D. NO. CITY OR TOWN STATE
<br />� DOA El Other ISP—ty
<br />BC CITY TOWN OR LOCATION OF DEATH
<br />_T_ -- I
<br />27a DATE OF DEATH lMo Day Yr)
<br />Bo INSIDE CITY LIMITS
<br />8e COUNTY OF DEATH
<br />Grand Island
<br />E o"—,
<br />Yes H No ❑
<br />Hall
<br />9a RESIDENCE STATE
<br />9b COUNTY
<br />g
<br />9c CITY. TOWN OR LOCATION
<br />_
<br />9d STREET AND NUMBER Ilncludmg Zip Codel 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />2Ba On the Oasis of examination and or mvesbgalion, m my opinion death occurred at
<br />the lima, date and place and due 10 me cause(s) stated.
<br />Grand Island
<br />20 South Oak Yes "°
<br />10 RACE - (e g.. While Black. Amencan Indian
<br />11. ANCESTRY fe g.. Italian. Mexican. German, etc)
<br />12. ❑ MARRIED © WIDOWED
<br />13 NAME OF SPOUSE (It wife give ma,cen Hamel
<br />etc.) ISoecdy)
<br />White
<br />fsoecafy)
<br />Irish
<br />En lish
<br />NEVER DIVORCED
<br />(Signature and Title) ► —
<br />OCCUPATION IGrve kind of work done during most
<br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />1Ab KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpecity only highest grade completed)
<br />Elementary or Secontlary IO -12) College ' 1 o•
<br />rbnq Ir /e even Arehred)
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type a Prrnp
<br />Ramchander Kamath, MD, VA NWI--CS, 2201 N Broadwell Ave, Grand TslanI 68803
<br />intenance
<br />32b DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />Hos ital
<br />12th Grade
<br />r14,ISU,AL
<br />ER NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />ec) Alvy NMN
<br />Moore
<br />(dec) Luella Jenner
<br />Yes unk 1 ` IIt yes give war and dates of se, -desl
<br />Yes �Wii/3- 2'(- 43/1L-U4 -47 i Yvonne nougeau
<br />191, INFORMANT MAILING ADDRESS (STREET OR R F D NO CITY OR TOWN. STATE. ZIPI
<br />137_S ria Road Lake Charles LA 70607 _ __— _
<br />20 EMBALMER - SIGNATURE B LICENSE NO 21 a METHOD OF DISPOSITION 21b DATE 21 CT CEfv1ETEBY OR CREMATORY NAME
<br />Central Nebraska
<br />Not Embalmed ❑Banal ❑Removal Jul 28, 200 _-
<br />22a FUNERAL HOME -NAME 21d CEMETERY OR CREMATORY L A 0 I OR O A7F
<br />Kleine Funeral Home Cremation ❑Donation Gibbon, Nebraska _ -
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN. STATE. ZIP)
<br />3213 W North Front St., Grand Island, NE 68803
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tat. (b). AND (c)) Interval between onset and death
<br />PART
<br />I
<br />I I., Metastatic Liver Disease Da s -
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onsel and oeam
<br />I
<br />I
<br />,bI Cholangiocareinoma Unknown
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and seam
<br />Icl I —
<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />2a AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS,
<br />DiIabete_ s CAD PVD COPD
<br />(Ages 10-541 Yes —
<br />Yes "°
<br />Yes No
<br />26a 126b DATE OF INJURY /MO. Day. Yr.)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED -
<br />A,--, LJ Undetermined
<br />M
<br />Su,ade Pending 126e INJURY AT WORK 261 PLACE OF INJURY - At Fame. )arm. street. factory
<br />26q LOCATION STREET OR R F D. NO. CITY OR TOWN STATE
<br />_j o8de building. etc Ispecify)
<br />CH °micide Invesligali0n Yes No ❑
<br />�1
<br />-
<br />_T_ -- I
<br />27a DATE OF DEATH lMo Day Yr)
<br />28a DATE SIGNED (Mo Day Ycl 28b TIME OF DEATH
<br />;8 2000 �� _
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<br />E o"—,
<br />�Ju�
<br />27b. DATE SIGNED /MO Day Yr I 27c TIME OF DEATH
<br />$ r
<br />28c PRONOUNCED DEAD IMO Day. Yr.)
<br />28d. PRONOUNCED DEAD 'Houn
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<br />2Ba On the Oasis of examination and or mvesbgalion, m my opinion death occurred at
<br />the lima, date and place and due 10 me cause(s) stated.
<br />o
<br />27d To the best of my knowledge. d ath occurred al the time, dat n\ due to the
<br />° o
<br />'and
<br />Ca .said staled.
<br />V`
<br />IS. nature and Tidel ►
<br />(Signature and Title) ► —
<br />29 DID TOBACCO USE CONTRIBUTE TO THE OEATH7
<br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />WAS CONSENT GRANTED'
<br />7 YES F NO © UNKNOWN
<br />1-1 YES X❑ NO
<br />El YES © NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type a Prrnp
<br />Ramchander Kamath, MD, VA NWI--CS, 2201 N Broadwell Ave, Grand TslanI 68803
<br />32a REGISTRAR
<br />32b DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />tit,
<br />AUG 12000
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<br />LEGAL; S51 Lot One (1), Block 148, Union Pacific Railway Company's Second
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