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meN `HIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND, SrYRTEb+ ff CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Am THt NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE SEP 13 2000 200007813 LINCOLN, NEBRASKA HEALTH IAN SERVICES ONFILE WITH ION, WHICH IS STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAAI OWES MNANCE A146.SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH_` NAME DECEDENT NE FIRS' MIDDLE LAS' 2 SEX, 3. DATE OF DEATH IMnnlh Oar. Yedd Rex Virgil Klinginsmith Male ' August 27, 2000 4 CITY AND STATE OF BIRTH rrf not o U SA name ccur i 5a. AGE - Last Birthday I UNDER 1 YEAR UNDER I DAY 6 DATE OF BIRTH fbfonM. Day Year] (Rural) St. Paul, Nebraska IVrs 76 Jul Y 21 1924 5b Mp$ DAYS Sc. HOUR$ MINS 7 SOCIAL SECURTIY NUMBER 8. PLACE OF DEATH _ 506 -32 -8094 HOSPITAL ❑ Inpatient OTHER ❑ Nu ,h, Home ❑ ER Outpatient FRI Residence 8b FACILITY Name pf normshtuCon, give streel and number/ 1621 W. Hagge Ave ❑ DOA ❑ Othe, rSpec Jy 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNI V OF DEATH Grand, - Island, r-N raska - - Yes ND Ha 9a RESIDENCE - STATE 91) COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER ilnCiudlng Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1621 W. Hagge Ave Yes No ❑ 10 RACE (eg., White. Black Amencan Indian 11. ANCESTRY leg Italian. Mexican, German, etc) 12�y, MARRIED ❑ WIDOWED 13 NAME OF SPOUSE !If wife give maiden name/ elcl ISceclly White ISDecAYI Ger1T1aI'I ` ❑f NEVER DIVORCED Dennetta Palu MARRI D l4a USUAL OCCUPATION (Give kind of work done during moss 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecdy only highest grade completed) of wnrking life, even if rebredl Retired Grocery Store Manag Retail Food Elementary or Secondary 10 -12) College Il 4 or 5.1 2 16 FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDENVa S S On (dec) Robert Ellis Klinginsmith (dec) Lona Gertrude ifs- igi�ISi- 18 WAS DECEASED EVER W US ARMED FORCES? 19a. INFORMANT NAME ,Yes np pr pnk) III yes gve war and date, of se Yes WWII 6- 45/11 -4-4 6 Denetta Kl in g� insmith 19b INFORMANT MAILING AUDHESS IS] HttI OR H U NU.. CI I Y UH I UWN. J I A I t LIY! 1621 W. Hagge Ave. Grand Island, NE 68801 20 EMS SIC NAT('RF B LI N$ , O 21. METHOD OF DISPOSITION 21b DATE ?IC CEMETERYORCREMATORY NAME �Burial ❑Removal. August 31, 2000 Elffwoold Cemetery 22a FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Jacobsen- Greenwa, Fueral Home ❑ Cremation ❑ DDnatur St. Paul, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R. F.0 NO CITY OR TOWN. STATE, ZIP) 411 "0" Street St. Paul, NE 68873 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal Ib) AND Ic)I Interval between onset and death PART "%, % 121) lal DUE TO. OR AS A CONSEQUENCE OF / 6 Interval between onset and death fli 61 T i -6__)-, F - ' Y,- L Interval between onset and death OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONERS II (Ages 10 541 Yes No Yes No Yes No 26a 26b DATE OF INJURY IMO. Day. Yr.) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undele.'mineo M ! J Swade Pendlnq 26e INJURY AT WORK 26f PLACE OF INJURY -At home. farm street factory 26g LOCATION STREET OR R F D NO CITY OR TOWN STATE ❑ ❑ .11— building. etc. ISpecify/ Homlcltle Invesugauon yes No 27a DATE OF DEATH rMO Day Y j 28a DATE SIGNED iM0 0av v' 281b TIME OF DEATH v r 27b DATE SIGNED (Mo Day Yf) 27c TIME OF DEATH g E, 28c PRONOUNCED DEAD Mo Day, Y!I 2Bd. PRONOUNCED DEAD (Hourl E n J xg rn M M 27d To the best of my knowledge Ile urced at the time. date antl place and due to the _ i ° 28e. On the basis of exam.naoon and or invesegatkon. In my opinion deatn occurred al causelsl stated ' q the time. date and place antl due to the causels) stated ISlgnature and TINeI ► IS. nature antl Tluel ► 29 DID TOBACCO USE CONTRIBIJ TE TO EATHO 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' . 30. 30 bCONSENT GRANTED' ❑ YES ❑ NO UNKNOWN ❑ YES NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER !PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, rYpe or Pnnf1 Ghulam Mirza MD VA Medic enter 2201 N Broadwell Grand Island NE 6803 32a REGISTRAR I 32b DATE FILED BY REGISTRAR i'Mo.. Day Yr) �, SEP 12 2000