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1180
<br />STATE OF NEBRASKA
<br />WHEN ` THIS 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 />DATE OF ISSUANCE
<br />07/08/2016
<br />LINCOLN, NEBRASKA
<br />201804438
<br />STATE OP NEBRASKA - DEPARTME
<br />CE;_, F
<br />O
<br />LTH AND HUMAN SERVICES
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1+ DECEDENTS -f4AME (First,
<br />Lar Den Cook
<br />4. CITY AND STATE OR TERRi
<br />Y. OR FOREIGN COUNTRY OF BIRTH
<br />6b. UNDER 1 YEAR
<br />MOS. DAYS
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE. OF DEATH (Mo
<br />June 27, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 28, 1937
<br />4-47,06
<br />ACFLITY -NAME (
<br />Veterans Affairs Medical Center
<br />t}on, glue street and number)
<br />es. RESIDENCE STATE
<br />Netras
<br />11,.F'AY.
<br />Virgil:
<br />Loot, Suffix)
<br />IN U.S, ARME FORCES?
<br />(Yea, Nt, of U ntc)- Ye-
<br />0812
<br />daces o f service N Y.s.
<br />954- OS/22/1957
<br />.::: ifi�.:ME;T'HOCOF',04SPOS(
<br />fiPnr
<br />�drAnsetvta �}Enw
<br />Qoom.Yri:; QOth.
<br />ant *180111 42 days W death
<br />le nt 43 days to 1 year before death
<br />t the past year
<br />9b. COUNTY
<br />Hall
<br />18a, EMBALMER - SIGNATURE
<br />Not Embalmed
<br />164 CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />22ti, TIME OF INJURY
<br />m
<br />as FLACEOF DEATH
<br />(4QSPrr 14 tnpati001
<br />Q EA?O utpationf
<br />0 DOA
<br />OBEB; Q Nursing Home /LTC
<br />0 Decedents Home
<br />0 Otb.r(Spocly)
<br />80. CITY OR TOWN -UF DEATH (Include YIP Cook)
<br />Grand Island 68803
<br />6d. COUNTY OF DEATH
<br />Hall
<br />Sc, CITY OR TOWN
<br />Grand Island
<br />ad. ST SETANOta(3MBER
<br />41 Prairie Ridte La
<br />KN. MARITAL STATUS AT liME Or DEATH Method Q Never Startled
<br />i, , kparrled, bid eeperated Q W1Odwed Q Divorced 0 Unknown
<br />100, NAME OF SPOUSE (First, MiddI
<br />Janet Kay .Bressler
<br />rd. ZIP CODE
<br />68803
<br />die. ol maiden name.
<br />go.APT. NO.
<br />12 MOTHER'S• (Fir
<br />Beulah Cal/mill
<br />Middle, Malden Surname)
<br />14a. INFORMANT -NAME
<br />Janet Ka Cook
<br />CITY!TOWN
<br />Gibbon
<br />DUE TO, OR AS A CONSEDUENC
<br />Y1 AU c)
<br />DUE TO. OR AS A CONSEQUENCE
<br />OR AS A CONSEOU
<br />17L;FUNERAL 1 515 NAME AND MAILING ADDRESS (SUM, City or Town, SERIA)
<br />4{l Funeral Home, 2929 S. Locust Street, Grand tslard, N
<br />CAUSE OF DEATH (See rostra of
<br />icau ora tram directly tatat00 the damn. fin NBR a1er Omni.]
<br />ptir,LgY DO HOT AaeRE:,l., E. Eaer 000; and taws. on a Me.
<br />I . PART I; Go
<br />mgi(4enr
<br />Sequentially fist H
<br />nd ex miles)
<br />11Th. Zip Coda
<br />686a1
<br />APPROX INTERVAL
<br />onset to death
<br />24c. PRONOUNCED DEAD (Mo.,
<br />14b, RELATIONSHIP TO DECtrOENT
<br />Wife
<br />16c. DATE (MO,. Day, Yr.)
<br />June 29, 2016
<br />OW I NJURY OCCURRED
<br />22c. PLACE IN
<br />2ta. MANNER OF DEATH
<br />rur 0 titeniaide
<br />cidetit t ( Peeing Invesdpetion
<br />Q Stec Cook) not be dbtsr0Nnad
<br />ae buifdimg, +: onetruoAOn alto, MC. t
<br />R Y•S
<br />UM BER, APT. NO. C
<br />TE SIGNED (Mo., Day, Yr.)
<br />STATE
<br />24b. TIME 0
<br />ay, Yr.)
<br />occurred at Me Ore,
<br />neturs and Tin.)
<br />M.'.•134471t. C,,,* LI GO
<br />YES Li NO
<br />r ROUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />21b, IF TRA SPORTATION INJURY
<br />Q Qd
<br />Q Passenger
<br />Q Pedestlien
<br />Q Other (Specify(
<br />21c, WAS AN A
<br />0 YEA
<br />21d, WERE AUTOPSY EtivORK4E AYAI).A
<br />TO COMPLETE CAUSE OF DEATH?
<br />A YES NO
<br />_ gettdn.. t*rr bp}illbtt 400d
<br />t�h0 time, chin a nd place acrd due to the Cause(a) stated. (thAnatatti
<br />of examination
<br />OS)
<br />2Sb. DATE FILED BY R
<br />JUL 6 ,0
<br />
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