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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MERV/CES
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE£4RD ON FILE NTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM$ gECTIO_N, W CH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />SEP 14 2000 , ''1 �' 6 3 la
<br />iA2 eoo
<br />ASSIXTANF STATE REGIS#WIC
<br />LINCOLN, NEBRASKA HEALTH AND H1*AK8E*WC8W2YStEfi#:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE$+_{Nr1NCE A?4D SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />� I
<br />F,
<br />DECEDFNi NAME FIRST
<br />MIDDLE LAST
<br />— - - -- - -
<br />SFX 1 i.11r 1F DEATHH M ,tt, (I. ri 1'eaW
<br />Carroll
<br />A. Larson
<br />Male August 29, -2000
<br />UNDER DAY 6 DATF OF RIRIH ,Month 2u read
<br />CITY AND STATE OF BIRTH dtnotm USA namecountryl 5a AGE Last Blnhday
<br />UNDER YEAR
<br />Y's I
<br />7c HOURS MINS i
<br />5b MOS DAYS
<br />D
<br />81
<br />_
<br />�
<br />m
<br />SOCIAL SECURTIY NUMBER
<br />1 28, PRONOUNCED DEAD 'M nay v,
<br />8a PLACE OF DEATH
<br />TIME OF DEATH
<br />5,`35 M
<br />E n,
<br />°
<br />HOSPITAL L_J loauent
<br />OThLP Vu. ny 1
<br />507 01 1254
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<br />ER Outpatient Nesden�
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<br />DOA Cull" So - --
<br />lo CITY TOWN OR LOCATION OF DEATH
<br />86 INSIDE CITY LIMITS ee COUNTY OF DEATH
<br />_
<br />Yee Np �1
<br />Hall
<br />1a RESIDENCE -STATE COUNTY
<br />9c CITY TOWN OR LOCATION
<br />9d STREET AND NUMSF= 1. q o-fe "�ti1UE CITY I.IMII S
<br />�11
<br />Nebraska Hall
<br />Grand Island
<br />1405 H 34 _WL_68801 Yes) No ❑
<br />=
<br />I I ANCESTRY
<br />le g Italian. Mex,can. German, etc[
<br />12. © MARRIED
<br />C7 I-
<br />CD
<br />[specify)
<br />American
<br />NEVER
<br />MARRIED
<br />I'I
<br />DIVORCED
<br />Nellie_ I. Heath
<br />14a USUAL OCCUPATION [Give kind of work done during
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<br />Idb HIND OF BUSINESS INDUSTRY
<br />rri
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<br />� 15 EDUCATION ��oec�l� n1y n,ghest grade rompleletll
<br />of wobung life. even it retired)
<br />EII ementa,, or Secondary 0 12) College
<br />Maintenance
<br />AqTiculture
<br />12th Grade
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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MERV/CES
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE£4RD ON FILE NTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM$ gECTIO_N, W CH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />SEP 14 2000 , ''1 �' 6 3 la
<br />iA2 eoo
<br />ASSIXTANF STATE REGIS#WIC
<br />LINCOLN, NEBRASKA HEALTH AND H1*AK8E*WC8W2YStEfi#:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE$+_{Nr1NCE A?4D SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />� I
<br />F,
<br />DECEDFNi NAME FIRST
<br />MIDDLE LAST
<br />— - - -- - -
<br />SFX 1 i.11r 1F DEATHH M ,tt, (I. ri 1'eaW
<br />Carroll
<br />A. Larson
<br />Male August 29, -2000
<br />UNDER DAY 6 DATF OF RIRIH ,Month 2u read
<br />CITY AND STATE OF BIRTH dtnotm USA namecountryl 5a AGE Last Blnhday
<br />UNDER YEAR
<br />Y's I
<br />7c HOURS MINS i
<br />5b MOS DAYS
<br />Uehling, Nebraska
<br />81
<br />_
<br />_ December . 2
<br />—�
<br />SOCIAL SECURTIY NUMBER
<br />1 28, PRONOUNCED DEAD 'M nay v,
<br />8a PLACE OF DEATH
<br />TIME OF DEATH
<br />5,`35 M
<br />E n,
<br />°
<br />HOSPITAL L_J loauent
<br />OThLP Vu. ny 1
<br />507 01 1254
<br />o 0 0
<br />ER Outpatient Nesden�
<br />Ib FACILITY - Name 'If nol ostauhon. give street and number)
<br />Beverly Healthcare at Lakeview
<br />DOA Cull" So - --
<br />lo CITY TOWN OR LOCATION OF DEATH
<br />86 INSIDE CITY LIMITS ee COUNTY OF DEATH
<br />Grand Island
<br />Yee Np �1
<br />Hall
<br />1a RESIDENCE -STATE COUNTY
<br />9c CITY TOWN OR LOCATION
<br />9d STREET AND NUMSF= 1. q o-fe "�ti1UE CITY I.IMII S
<br />�11
<br />Nebraska Hall
<br />Grand Island
<br />1405 H 34 _WL_68801 Yes) No ❑
<br />10 RACE - leg, White. Black. American Indian
<br />I I ANCESTRY
<br />le g Italian. Mex,can. German, etc[
<br />12. © MARRIED
<br />❑ WIDOWED 13 vAME OF SPOUSFl P wdo ,ewe made,' "a -rre)
<br />etc I ISoec,tyl
<br />White
<br />[specify)
<br />American
<br />NEVER
<br />MARRIED
<br />I'I
<br />DIVORCED
<br />Nellie_ I. Heath
<br />14a USUAL OCCUPATION [Give kind of work done during
<br />g moll
<br />Idb HIND OF BUSINESS INDUSTRY
<br />-. h
<br />� 15 EDUCATION ��oec�l� n1y n,ghest grade rompleletll
<br />of wobung life. even it retired)
<br />EII ementa,, or Secondary 0 12) College
<br />Maintenance
<br />AqTiculture
<br />12th Grade
<br />Oliver NMI T,arson _ Anna_._ _NMI - Tarsgr.
<br />18 WAS DECEASED EVER IN US ARMED FORCES' II ___ T19a WFORMANT NAME
<br />fyes no unk I if yes give ", and date, nl sarvlee' `w
<br />Yes 08/20/43 - 03/03/45 Nellie I. Larson
<br />t9b INFORMANT MAILING ADDRESS ISTREET OR H F D NO CITY OR TOWN STATE ZIPI
<br />1019 S. Pine Street, Grand Island, Nebraska 68801 _
<br />20 EMBALM_ ER - SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION 21b DATE HV OR C,RE MnI IR" NAME
<br />--/ x Burial Remova, Sept. 1, 2000 Baptist Cemetery
<br />22a. FUNERAL HOM E T21d CEMETERY OR CREMATORY LOCA ^rip 'ilr -TOWN STATE
<br />Kleine Funeral Home Cremation ❑ Donator Hooper, Nebraska
<br />22b FUNERAL HOME ADDRESS ISTREET OR R.F.D NO CITY OR TOWN. STATE. ZIP)
<br />3213 W. North Front St., Grand Isl
<br />IMMEDIATE CAUSE TENTER ONLY ONE CAUSE PER LINE FOR Ial lb) . AND Ich Interval between onset and death
<br />ART
<br />lal Widesprece_d me�aatah'c_ melanom L l!J %�h C'erehr<2. /., adre�n4/;/ orcx.
<br />DUE TO, OR AS CONSEQUENCE Of Pa / /%IO/ll1 /•� lld Ae �e �� �Q Sit, een onset and death
<br />Ib) K s
<br />DUE TO OR AS A CONSEOUENCE OF Inlervat tvtween onset and death
<br />Ic)
<br />OTHER SIGNIFICANT CONDITIONS Conditons contributing to the death but not related PART III IF FEMALE WAS THERE A N__ 1 To) T wA , T tFFERRFD TO MEDICAL
<br />PART fj rO =;C /t ro
<br />VI /j'•`y r C �/ `� //f PREGNANCY IN THE -AST 3 MONTHS' FYANf t )P (')PONE Rn
<br />II It' fiL L �lclic��I�JC LCr ��J(�(�
<br />C. �� ✓_ Pi� %� % /i Ages v oai ve
<br />260 26b ATE OF II�URV 'Mo Day Yrl I 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY t)CCI IRRFD
<br />Accident jndet.,ned ;
<br />L J Sucde � Pentllnq 26e INJURY AT WORK
<br />Homichtle Investgalron Ves No
<br />276 DATE OF DEATH 'Mo Day. Yr )
<br />`� -,%q DU
<br />276 DATE SIGNED (Mo Day Yrl 2�
<br />F0 q-
<br />8
<br />>j10 To the best of my knvletl .death netl at thy
<br />c cause's) stated _
<br />I M
<br />_
<br />261 PLACE OF INJURY At home . farm street facto,v
<br />1264 LOCATION �TIIFF' �+ , NO
<br />, 1H TOVjN STAfF
<br />off ce bwltlmg. etc 'Specify)
<br />_428a
<br />;)ATE SIGNED 11-10,11
<br />28h T MF 'JF DEATH
<br />,:.
<br />>-
<br />1 28, PRONOUNCED DEAD 'M nay v,
<br />M
<br />26d PRONOVNt, I DEAD NOUr:
<br />TIME OF DEATH
<br />5,`35 M
<br />E n,
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<br />h o e and place antl tlue to the
<br />o 0 0
<br />28e On the bas s of examinai, o �r nvesl on.
<br />1n my op n o1 �heahl ,c eo a1
<br />qat
<br />. the time. dale and place a d rtue Io the ,a L5eIY
<br />.ur
<br />staled
<br />20 DID TOBACCO USE CON TRI UTE T E D H? Via HAS ORGAN OR TIS A DONATION BEEN CONSIDERED' 30tl WAS CONSENT GRANTED'
<br />I ``
<br />YES NO UNKNOWN YES NO YFS NO
<br />31 NA D ADDRESS OF RTIFIE HYSICIAN, CORONER VSICIAN OR COUNTY ATTORNEYI /Type or Prmn
<br />- ) v�.n tSGn, %dip.
<br />Ric d M. Fruehling MD, 2A6 V. F, iAy Ave., Grand Island, Nebraska 68803
<br />32a REGISTRAR •..�.M�n, 32b DATE FILED BYgEflIWAI /Op D,7rK p1 n
<br />
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