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<br />9tl STREET AND NUMBER /Inchrdrng Zip ('prier
<br />�9e INSIDE CITY ,!eTFF.
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<br />Bartlett
<br />Box 53
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<br />Yes �] N1;
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<br />q.. Italian. Mexican. German. etc/
<br />t2 ❑ MARRIED
<br />®WIDOWED
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<br />ill wrlr give mn namer
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<br />lSpect
<br />Swiss
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<br />Cecil R.
<br />C:D
<br />14a USUAL OCCUPATION Grve kmdot work done during most
<br />Of k ,Q Irle.
<br />tab KIND OF BUSINESS INDUSTRY
<br />CAI
<br />r v
<br />grade compleledl
<br />even .l ref red/
<br />Homemaker _
<br />co
<br />o, Secondary '0 121
<br />i
<br />College
<br />16 FATHER -NAME FIRST MIDDLE
<br />D
<br />W
<br />MAIDEN SURNAME
<br />'
<br />Bernice
<br />Huff
<br />Cn
<br />19a INFORMANT
<br />CJ)
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<br />WHEN THIS COPY CARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEK R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOMC PME IM/TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STFGe$EjdItO , W iCkjS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />BATE OF ISSUANCE
<br />JUL 200006836: _� - -
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES_SYBTEM`
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN ANCF AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE O_ _F DEATH
<br />'�': Jt_Nl NA41E FIRS' MIDDLE - - -- LAST 2 SEX '' -J DAiE OF DEA" iH - - ----
<br />M;�r.r %zh 1•an
<br />__ ADA_ IRENE _ ATKINSON Femal*e I 4 July 2000
<br />T (.ITV AND STATE OF BIRTH ,1 not in USA name country/ Sa- AGE - Last Birthday UNDER I YEAR UNDER 1 DAY 6. DATE OF 31111 H Mom, Dav Year)
<br />IYrs 1 51, MOS DAYS Sc. HOURS MINS
<br />Bartlett, NE 85 6 Aua. 1914
<br />7 " I'AL SECURTIY NUMBFR
<br />_ 505_ 12 2397__
<br />9h FACILITY Name /!l not
<br />__ Box 53, Bartlett
<br />8r'. (' IT' r�)WN OH L7— ON )F DEATH
<br />Rnrt1 c, tt-
<br />street and number)
<br />8a PLACE OF DEATH
<br />HOSPITAL. ❑ mpatienf
<br />ER Outpatient
<br />DOA
<br />8a INSIDE CITY
<br />I
<br />CIITY LIMITS
<br />-T Be COUNTY OF DEATI
<br />Yn, Iv .. I I I r, - _ , _
<br />OTHER ❑ 11-1.11c H -In
<br />® Resdence
<br />Other ,jpe<-dy�wn V
<br />Garden
<br />3a RESIDENCE - STATE
<br />9b COUNTY
<br />9c CITY, TOWN OR LOCATION
<br />9tl STREET AND NUMBER /Inchrdrng Zip ('prier
<br />�9e INSIDE CITY ,!eTFF.
<br />Nebraska
<br />Wheeler
<br />Bartlett
<br />Box 53
<br />I
<br />Yes �] N1;
<br />10 RACE le.g.. White. Black American Indian
<br />etc./ (Spec
<br />1I ANCESTRY le
<br />q.. Italian. Mexican. German. etc/
<br />t2 ❑ MARRIED
<br />®WIDOWED
<br />13 NAME OF SPOUSE
<br />ill wrlr give mn namer
<br />-ty'1
<br />Cauc.
<br />lSpect
<br />Swiss
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<br />NEVER
<br />MARRI
<br />DIVORCED
<br />Cecil R.
<br />Atkinson dec'_c
<br />14a USUAL OCCUPATION Grve kmdot work done during most
<br />Of k ,Q Irle.
<br />tab KIND OF BUSINESS INDUSTRY
<br />1 I S EDUCATION (Specify oniy hqnest
<br />~Elementary
<br />grade compleledl
<br />even .l ref red/
<br />Homemaker _
<br />making
<br />o, Secondary '0 121
<br />i
<br />College
<br />16 FATHER -NAME FIRST MIDDLE
<br />LAST 17 MOTHER
<br />FIRST MIDDLE
<br />MAIDEN SURNAME
<br />EduTin Pletcher
<br />Bernice
<br />Huff
<br />IS WAS DECEASED EVER IN US ARMED FORCES'
<br />19a INFORMANT
<br />---
<br />;Yes no er 11- 11 11, ar and dak:s of servcesl
<br />�
<br />No
<br />I Cheryl Kremer
<br />vn 1rvr-- rtAILINU ADDRESS (STREET OR R D NO CITY OR TOWN. STATE. ZIP)
<br />_ __ _EN _ 799 H Rd. Chapman,-NE-68827 _
<br />20 EMBA Tr/Rf_aL10ENSO 21a. METHOD OF DISPOS',TION i21b DATE 21C CFMET =RYOH _ER r,1A rORr NAME
<br />__' *HOMMF42 ❑Burial ❑Remeyal 7 July 00 i Nebr Cremation Service
<br />72a FUNERAL 21d CEMETERY OR CRE MA TOgY LOCATION CITY �rR TOWN STA. TF
<br />Huffman's Brooks Chapel �Crematgn ❑°°na" Norfolk, Nebraska
<br />22b FUNERAL HOME ADDRESS fSTREET OR R D. NO CITY OR TOWN. STATE. ZIP) — - - - --
<br />Box 199, Elw
<br />PART in,-NE 68636
<br />23 IMMEDIATE ( . AUSE TENTER ONLY ONE CAUSE PER LINE FOR lal (b). AND Ic)I Interval beween cnsel aria s
<br />'
<br />a1 Natural Causes
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset anrrv,v
<br />Ib
<br />- - -_. _ — _-__ -_.._
<br />DUF 70 )R AS A CONSEQUENCE OF 'Mt al between. onset,,,;
<br />Ic)
<br />OTHER SIGNIFICANT CONDITIONS Coodmons contributing t0 the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSy 25. WAS CASE REFERRED 10 ME LIIC: n.
<br />PAf7T PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR COHONF IT'
<br />(Ages 10 -SQI Yes [ No Ves No Yes_- -NO L�
<br />-oa T26b ='HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCU RREO
<br />7M
<br />l- J 9u�ede j Pendmq 25e INJURY AT WORK 261 P ACE QF INJURY At home ta— street. factory 26g LOCATION STREET OR R.F D NO ".IT / OR TOWN ;T -1 t
<br />I, 11 ❑ ❑ office building, etc !,p cNy)
<br />Homrc�de �esugallon
<br />Yes No
<br />1
<br />—r27a DATE OF DEATH ;MO Day Yrl 28a DATE SIGNED lMo. Day Y,) 28b TIME OF DEATH
<br />_ _ 6 July 2000 _ n
<br />27b DATE SIGNED IMo. Day Yrl 27c TIME OF DEATH `>' 28, PRONOUNCED DEAD !Me Day Vrr 2Bd. PRONOUNCED DEAD ;.....
<br />L _ _ M ¢ _5 July 2000 _ 3: 00 P.
<br />L - - - --
<br />„ 2 Jd I a me best of my knowledge death occurred at the time. date and place and due to the o 0 0 2Be On the basis of examination and or myesngatlon, m my OD-on death occurred ar
<br />i cz users stated. ` the I'me date and place � due to the pyrytse(51 stated
<br />24 DID r08ACC0 USF CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.b W S CO SENT 11AN7E
<br />YES NO UNKNOWN YES NO F] YES WN.
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY, /Type or Pnnrl --
<br />James J. McNally, Esq., Wheeler Co. ty Coroner, Box 164 Neligh, NE 68756
<br />32a REGISTT 32b DATE FILED BY REGISTRAR /MO. Day. Yr/
<br />j /tom /L t• ��, 1 JUL 10 2000_
<br />Lot 8, Block 11, Packer & Barr Addition and Lot 3, Block 78, reeler & Bennett
<br />TF.ti 4 A.i -; + --; ., 04 +- _4F 0te.. -,..4 _r__1 .-._.a IT-1 -1 i+ - - - -i- " -L -- -'
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