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STATE OF NEBRASKA <br />M . T, ". <br />WHEN ! THIS ;r COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT <br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD <br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />r, <br />DATE OF ISSUANCE <br />5/8/2018 <br />LINCOLN, NEBRASKA <br />�.' �a t'?.ittATIY IMAM <br />506'24 -7338 <br />m F ACA.'TY:`.At61M .;. IMMY nou"M wet seat Ar.s nnn'Pr7 <br />St. Francis ;Medical Center <br />PART OT 8-510 * CONDITIONS • Candooes cderesuon U tM deem Wl Nit *MO <br />'2Be <br />at DATE OF 'IAMRY MAU. OM. Yr! 260 HOUR OF INJURY <br />A�QeM I O �" <br />� HO.uclde` <br />.. <br />2Ta.:..ATE QF 000+ IAA,. Dar. Tr) <br />r <br />219 DATE SIGNED rAa DMr Y ,, ... <br />II <br />277. 30R►9.1t0rgy <br />l(rwwl.7ge u..a <br />.: 57911Fe til T1r) <br />0:0010 <br />29. DID TOSACCQ USE CONTRIBUTE TO THE DEATH? <br />❑ , YES ❑ NO 1.g UNKNOW':Y <br />Ir <br />DUETCT. OR AS A: CQN <br />ml <br />DUE TO OR AS CONSEQUENCE OF <br />(41 <br />32a REGISTRAR <br />assumed M eM ems. dale Mal Glace NA Ow 10 iM <br />IT MOTHER <br />PART IS IF:FEMALE.WAS: A . <br />PREGNANCY IN THEPASI 3 MONTHS" ^ <br />IA9.s 15-54) Y., i No ® Ya I ! NO 71, <br />257:. DESCREIS OWIN;Il1AY OCCURRED <br />25o DATE SYONEC ■Ab. Day Yrl <br />�1 - i - 9 14 <br />25g LOCATION STREET OR R F D. NO. <br />Unknown <br />WIVE b.le.sn trove 501 <br />00er1Yal Maw once aro Rear <br />CITY OR TOW <br />OF DEATH <br />7.1 a. <br />255 PRONOUNCED DEAD 1440 <br />g 10— Z,5 -96 a . M <br />as On r best Y.0 wabon.rle a fwelog a o m, ow non Oeea Occ M <br />0118 TOO *AtNil <br />308 WAS CC RANTED' <br />U <br />,31. Now )NDADOFESSOF CERTIFIER (PHYSICIAN. CORONER S PHYSICIAN OR COUNTY ATTORNEY' fTypa or PMq <br />Elan L. Tbtzke, Hall County Attorney 117 • E 1st, Grand Island NE 688) <br />C°DENT - NAME <br />1,aretta <br />MAS <br />W ST147E W my w USA awe aG!Uyyl <br />05g Junction, Nebraska <br />TOWN:il+)TCAT IN OF DEATH <br />Grand island <br />OA FIFWHI-TICA - STATE. 95- COUNTY <br />Nebraska <br />Hall <br />0 RAS los-: Wr ae. sec A twtcen IndaIndust <br />14 .' <br />USUALO^UPATION. (Dan lad al <br />o <br />at ro ? %ro9C; <br />Home; Maker <br />his FATHER. NAME FIRST MIODLs <br />James <br />SEQUENCE OF <br />.Ica i <br />STATE OF NEBRASKA -- DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />ANDOLE <br />201803011 <br />LAST 2 SEX <br />Barnes Female <br />AGE - Eli SAMPay'. UNDER.' YEAR <br />HOSPITAL IN <br />(Val �9 So MOE DAYS <br />90 :PLACE OF DEATH <br />- w,p�rw+ OTHER <br />❑ ER O.Ao1Mn1 <br />D DOA <br />a COUNTY OF DE5TH <br />Hall <br />L- ' <br />M951R£ CITY LIW TS <br />I Yes J No <br />❑ <br />9c CITY. TOWN OR LOCATION <br />Grand Island 2423 Park Drive, 68801 <br />II. ANCESTRY fag. Imo. Mexican, German. Md s r (2 ® SOARED T' *DOMED 13 NAME OF SPOUSE /M *AP 4F+ maw! <br />. NEVER DIVORCED <br />❑ 1!A RIEFD <br />tab. KIND OF BUSINES:: INDUSTRY Earl K. Barnes <br />/Imo�* (IR 15. EDUCATION ISO.NY orW 1'9h M 7•''. cOP4N41 <br />1`,1v E4Y4W yW smorr.ry 10-12! c .1-4 0r5•I <br />a <br />- i: FIRST. <br />Domestic <br />LAST <br />Ellis <br />(9a INFORMANT -N <br />I Earl K. Barnes <br />ft WAY LECEASED`EVER IN U5: ARMED FORCES" <br />1v61. co. ar ink) I 19Ye5.. 9^ +ar am does si 31617.651 <br />No <br />INFORMANT MAILINGADORESS (ST OR R.F.D NO.. CITY OR TOWN: STATE 23P1 <br />2423 Park Drive, Grand Island, Nebraska 68801 <br />.. -: L • 21a METHOD CF NSNTOSITIO% <br />J � &Iw ❑ RennYal <br />KOLAS MN5 <br />Pauline <br />210' DATE <br />10/30/1996 <br />ALL.' <br />TUNERAL <br />Apfel- Butler Geddes Funeral Home i ❑ c [J oo. n Fairmont, Nebraska <br />225. FUNERAI, HOME ADORESS (STREET OR 4)F .D. NO :OTT OR TOWN. STATE 2Wi <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE DER LINE FOR w) IDI. AND IUI <br />Pa, Cardiopulmonary Arrest <br />STANLEY/¢. COOPER <br />ASSIST STATE <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />96 1 22:28 <br />3 DATE OF DE ATH r Nm, C., Y WI <br />October 25, 1996 <br />UNDER 1 DAY 1 a DATE OF &RTY. mom. Ds, Yawl <br />August 02, 1927 <br />84 STREET AND HUNTER IWCAAARIZP Coat! <br />MIDDLE <br />21c CEMETERYOR CREMATORY • NAME <br />Fairmont Cemetery <br />214 CEMETERY OR CREMATORY LOCATION CITY OR TOWN <br />1 9e INSIDE C TYLMtTS <br />I Yes <br />STATE <br />FAerval 0 AM Otam <br />Na <br />MAIDEN S1RNAMF <br />Rea <br />