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200105282 <br />Lot Two (2), Block Three (3), College Addition, Grand Island, Hall County, Nebraska. <br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG /NAL CORp 3311E �11111i <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA Mrfl= SECTIM. All- H IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS �. <br />DATE OF ISSUANCE r <br />A04_kv =S. Ci R <br />APR 2 6 2001 AEMTANT STATE REGISMAR <br />LINCOLN, NEBRASKA HEALTH ANaNUMANSERNCES-SVS_OM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SL PPORT <br />VITAL STATISTICS <br />CRR TTFTr A TF 01P' TIP A TT T <br />I DECEOEN7 NAME FIRST <br />MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH /Monet OR, Year) <br />Arthur <br />W. s <br />Male <br />August 22 2000 <br />4. CITY AND STATE OF BIRTH Ilf not rn USA.. name country) <br />(Ages 10 -541 Yes No <br />SDER <br />1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Mont, Day. Year) <br />S I DAYS <br />5c. HOURS <br />Oakland, Iowa <br />P <br />aM <br />wniind <br />Au st 14 1912 <br />7 SOCIAL SECURTIV NUMBER <br />261. PLACE OF. INJURY - qt ho . )arm. street. lactory <br />o ice ullding, <br />DEATH <br />Homicide investigation <br />❑❑ <br />479 24 9341 <br />etc. /Specify/ <br />Tel. <br />ITAL Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient rx-1 Residence <br />8b. FACILITY - Name /If not institution, give street and number) <br />2431 N. Park Avenue <br />27a. DATE OF DEATH IMO. Day vc/ <br />❑ DOA ❑ Other tswity <br />8c CITY TOWN OR LOCATION OF DEATH <br />28b. TIME OF DEATH <br />So INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />Grand Island <br />Yes n No ❑ <br />-_ ___ <br />Hall <br />9a. RESIDENCE - STATE 9b. COUNTY <br />CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER pncluding Zip Code/ 9e INSIDE CITY LIMITS <br />Nebraska Hall <br />19C <br />Grand Island <br />2431 N. Park Ave, 68803 Ye,]a No ❑ <br />10. RACE - (e.g.. White. Black American Indian 11. ANCESTRY (eg <br />Italian. Mexican. German, etcl 12. ❑ MARRIED <br />f= ] WIDOWED 13 NAME OF SPOUSE tN wde give maiden name) <br />etc.) (Sceafy) (Specify) <br />White <br />American <br />American MARK <br />DIVORCED <br />Berniece E. Foreman Dec, <br />14a USUAL OCCUPATION IGwe kind of work done during most <br />of working tile, even d rented) <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary (0.121 College I1 -4 or 5 • I <br />8th Grade <br />Farmer <br />A iculture <br />• <br />16. FATHER - NAME FIRST MIDDLE <br />LAST <br />MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />John H. <br />Nei hb <br />Fors <br />Martha J. Boyd <br />18 WAS DECEASED <br />EVER IN US ARMED FORCES' <br />19a. INFORMANT NAME <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />(Yes n0. Or Unk.) <br />III Vas give war and dates of services) <br />YES NO ❑ UNKNOWN <br />❑ YES ® NO <br />❑ YES NO <br />No <br />Wm_ *lark Bert-on, Da Coll ty Atty, 117 F 1st, Sand Ts1 nd NE 68801 <br />Dennis Neighbors <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1823 N. Custer Avenue Grand Isl N r s <br />20. ER - SI GNATURE 8 LICENSE NO. <br />21 a. METHOD OF DISPOSmON <br />21b. DATE <br />2tc <br />CEMETERY OR CREMATORY NAME <br />fMBA <br />' /U� <br />®Rubel ❑Removal <br />Aug. 25, <br />2000 <br />Westlawn Memorial Pk Cemet <br />22a. AL HOME NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />ine Funeral Home <br />- <br />1:1 Cremation 11 Donal -on <br />Grand Island Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY <br />OR TOWN. STATE. ZIP) <br />3213 W. North Front Street, Grand Island, Nebraska 68803 <br />PART nervai cerween onset ana oeam <br />I <br />I <br />R) Gunshot wmind to the hPgd iTnk oum <br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death <br />� I <br />(b) <br />DUE 70. OR AS A CONSEQUENCE OF - .. Interval between onset and death <br />I <br />Icl <br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />6 <br />IN THE PAST 3 MONTHS, <br />EXAMINER OR CORONER' <br />(Ages 10 -541 Yes No <br />Yes No <br />Yes No <br />26a <br />26b. D OF INJURY (Mo.. Day Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />F] Accident F] Undetermmetl <br />P <br />aM <br />wniind <br />5dSwede Pending <br />26e. RV AT W RK <br />261. PLACE OF. INJURY - qt ho . )arm. street. lactory <br />o ice ullding, <br />26g. LOCATION STREET OR F.D. NO. CITY OR TOWN STATE <br />Homicide investigation <br />❑❑ <br />Yes No <br />etc. /Specify/ <br />27a. DATE OF DEATH IMO. Day vc/ <br />28a. DATE SIGNED tW Day Yr.) <br />28b. TIME OF DEATH <br />approx <br />3a <br />�w <br />M <br />$ <br />i r <br />27b. DATE SIGNED (MO.. Day Yr.) <br />27c. TIME OF DEATH <br />28b ONOUNCED DEAD IMO.. Day. Yr.) <br />28d. PRONOUNCED DEAD (hour/ <br />M <br />• <br />27d. To the best Ot my knowledge. death occurred at the time. date and place and due 10 the <br />268. the basis of eiamina Ion and'01 inYestlgation, m my oplm0 ath oC f <br />a <br />rzw� <br />° Q �U <br />causelsl stated. <br />° <br />the time date and place and e t the eau <br />ISM nature and Title) ► <br />(SI nature and Title ► <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' <br />30 b WAS CONSENT GRANTED' <br />YES NO ❑ UNKNOWN <br />❑ YES ® NO <br />❑ YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY Tyoe or Print) <br />Wm_ *lark Bert-on, Da Coll ty Atty, 117 F 1st, Sand Ts1 nd NE 68801 <br />1,6-0G'I if F' ", ""'An ' tw) nnn rr, <br />i i r c� n � <br />