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200105839 The Northerly Eighty Eight (88) Feet of Lots One (1) and Two (2) in Block Eighteen (18), in Schimmer's Addition to the City of Grand Island, Hall County, Nebraska. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH &qD HIWAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL*6O0tp i*FL�WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sm TA39Yr A"#4 "%- THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ DATE OF ISSUANCE I{IfIIMY`& CQMR RIA z SEP 7 2000 200105839 A r kfSriREG1SYRAR LINCOLN, NEBRASKA HEALTH /1 JV NRVI93 SEEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND M MASfi F-s Fi1Vk A SUPPORT VITAL STATISTICS; _ CERTIFICATE OF DEATH , 1 DECEDENT NAME. FIRST MIDDLE LAST 2 -- - -- - -- Dennis Roy McGee M Male S Se tember 2 2000 4. CITY AND STATE OF BIRTH %11 not rn U SA name country) 5 5a AGE - Last Birthday I U UNDER I YEAR U UNDER I DAY 1 1 6. DATE OF BIRTH 'Month. Day Yearl (Yrs) S Sb MOS I DAYS 5 5c HOURS MINS Schuyler, Nebraska_ 6 63 _ _ I IJanuary 12 1937___ 7 SOCIAL SECURTIY NUMREP e ea PLACE OF DEATH 508 -46- 712_0__ - HOSPITAL " Inpallent OTHER ❑ Nursing 8b FACILITY Name 111 notmsrution, give street and number/ ❑ St . Francis Medical Center ❑ ❑ DOA ❑ Other Soe.n — Bc CITY TOWN OR LOCA n,.-rtl OF DEATH - (COUNTY O 9a RESIDENCE STATE 9 9b COUNTY T GI7V. TOWN OR LOCATION 9 9d STREET AND NUMBER /IrrGuding Dp Code! 9e INSIDE CITY u, +ITS Nebraska H Hall r Tc G 621 West 13th Yes❑]C No DUE FO. OR AS A CONSEQUENCE OF '.J \ 1 Interval beLwoen Onset and aeatr (0 r _ OTHER SIGNIFICANT CONDITIONS ConcElons contobuting to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER' I ❑ j gest0 -541 Ves 'JO Yes " Ves No AT u I-�_ _.__. 25a 26b DATE OF INJUR'/ ;Mc Day. Yr./ 261, HOUR OF INJURY 260 DESCRIBE HOW INJI RY -)C' =URRED I Accoent7Ilae1e^l -red S ne �o 26e. INJU RV AT WORK 76f PLACE OF INJURY At home lam street factory 26g LOCATION STREET OR R.F D NO C,Iry OR TOWN STAr. H 27ae DATE OF DE�gdl nn Ves NO ❑ 0ce building. etc ISpeedy/ es L_____i - DATE INkr l7nv vr) 28. DATE SIGNED Mo Day ✓r 1 1 28b TIME OF DEATH IM iJ 27b DATE SIGNED IMO Day Yrl 27c TIME OF DEATH $ �' r 28c PRONOUNCED DEAD IMO Day. Yr) —1280. PRONOUNCED DEAD /HOU/ o 0 27d I TI the `Jest Of m kn ath ocr "�reb at - '� ' n the lime dale "and lace and due o the cause sl .. n r ► P 1 1 M M ' y 1ne Ilme. dal? a d place antl due In Inc 28e On the ba515 Of exdminall0n and Or Invest gdt On, Irt my Op�n1On death occurred al came 9 satetl / s - stated. DID TOBACCO USE CONTRIBUTE TO TH€ D TH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.D WAS CONSENT GRANTED' ❑ "ns ❑ NO UNKNOWN ❑ YES 0 NO ❑ vES © NO NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY. Type a Pnn11 Ryan D. Crouch, M.D., 8 0 Alpha St. Grand Island, Nebraska 68803 _ RFGISTRAR - _— 32b DATE FILED BY REGISTRAR nnlMO. Day Yr)