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<br />WHEN THIS COPY CAMMES THE RAISED SEAL OF THE NEBRASKA HEALTH I
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL I
<br />THE NEBRASKA HEALTH AND HI(MAN SERVICES SYSTEM, VITAL STATim
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />FEB 3 20001 20000829
<br />A
<br />LINCOLN, NEBRASKA ASSISI
<br />HEALTH AND HUI-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEE
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />CD
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<br />- "- " " "" •''� MIDDLE LAST
<br />2 SEX 3. DATE OF DEATH Mnrrrh Dap Yearl - - -__-
<br />Richard J.
<br />1 4 Ci7Y AND STATF
<br />Mullen
<br />Male January 25, 2000
<br />OF BIRTH (#not,n US 4. name country)
<br />Sa AGE - Last Birthday UNDER 1 YEAR
<br />UNDER 1 DAY 6. DATE OF BIRTH --
<br />lMOnM. Dav vearl
<br />Chicago, Illinois
<br />C.J'1
<br />Sc. HOURS' MINS
<br />7. SOCIALSECURTIYNUMBER
<br />�/L NKNOWN
<br />-T
<br />X ❑ YES Np
<br />_ (ol 10 y 1
<br />iDUE TO. OR AS A NSEOUENCE �-
<br />Ba. PLACE OF DEATH - -_.
<br />tV
<br />Interval between o sel and death
<br />HOSPITAL ❑ Inpatient OTHER n Nursing Home
<br />❑ ER Outpatient ❑ Residence
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<br />- "- " " "" •''� MIDDLE LAST
<br />2 SEX 3. DATE OF DEATH Mnrrrh Dap Yearl - - -__-
<br />Richard J.
<br />1 4 Ci7Y AND STATF
<br />Mullen
<br />Male January 25, 2000
<br />OF BIRTH (#not,n US 4. name country)
<br />Sa AGE - Last Birthday UNDER 1 YEAR
<br />UNDER 1 DAY 6. DATE OF BIRTH --
<br />lMOnM. Dav vearl
<br />Chicago, Illinois
<br />Vrsl 74 5b MOS DAYS
<br />Sc. HOURS' MINS
<br />7. SOCIALSECURTIYNUMBER
<br />�/L NKNOWN
<br />January 18, 1926
<br />X ❑ YES Np
<br />_ (ol 10 y 1
<br />iDUE TO. OR AS A NSEOUENCE �-
<br />Ba. PLACE OF DEATH - -_.
<br />353 -14 -9999
<br />Interval between o sel and death
<br />HOSPITAL ❑ Inpatient OTHER n Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />be FACILITY -Name / lint ,nstifufion.givesbeetawnumber)
<br />St. Francis Skilled Care
<br />Center
<br />❑ DOA ❑
<br />do GTY TIIYJNDR.00ATic:; `. ?r pFpTN
<br />Other(Spec,fp- _ - -- .
<br />,
<br />1
<br />' Grand Island-
<br />a RESIDENCE - STATE 9b COUNTY
<br />8d. INSIDE CITY LIMITS ee COUNTY OF DEATH -- --
<br />Yes ® No ❑ _ Hall
<br />91 CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (intruding Pp Lade) - 9e INSIDE CITY LIMITS
<br />Nebraska Hall
<br />10 RACE White.
<br />Grand Island 326 Mallard Lane 68801 Yes ® "u ❑
<br />le. g., Black American Indian i 1 ANCESTRY le.g.. Italian. Mexican. German, etc; 72 ® MARRIED -
<br />❑ WIDOWED 13 NAME OF SPOUSE (ll wile give maroon name/
<br />etc I ISpesilyl
<br />(SPec-hl
<br />White _
<br />Taa USUAL
<br />Irish NEVER DIVORCED
<br />MARRI Margaret Faubion
<br />OCCUPATION rGrvek,ndolwakdoneWiingmosl
<br />of work /ilex even it retired,
<br />tOb KIND OF BUSINESS INDUSTRY
<br />Manu f a e t u r in Automotive 15 EDUCATION ISpeciry only highest grade completed)
<br />g-
<br />Chief Executive Officer
<br />_
<br />Elementary dr Secondary 10 -, 21 cmle a 1, cor -
<br />Service Equipment 4
<br />Ygears
<br />16 FAIHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Thomas _
<br />t8
<br />Mullen Kathryn Fenton
<br />AS DECEASED EVER IN U.S ARMED FORCES?
<br />, 9a INFORMANT -NAME --
<br />- - -_
<br />IYes ,c nr t,nk_I 11 :n- q-re war an:1 tlates of services)
<br />Yes I �W`p,[ II Dates Unknown Margaret Mullet, - Wife
<br />1b INFORMANT MAILING ADDRESS
<br />'STREET OR R D NO.. CITY OR TOWN STATF 71PI
<br />'2 tar Lane, G_r_a_ld _Island, Nebraska 68801
<br />20 E MER- SIGNATU 8 _NSE 21a METHOD OF DISPOSITION 27 b. DATE 21c CEMETERY OR CREMA TOR, NAME
<br />�� v r ❑Burial ❑Rammiai Jan. 28, 2000 Central NE Cremation Ser_v.
<br />4F;JNERALL H ME -NAME 21d CEMETERY OR CREMATORY LOCATION
<br />CITY OR TOY.'N STATE
<br />Livingston- Sondermann F H 1:X Cremation F-] Donator i Gibbon, Nebraska
<br />ir99h T—FRe --
<br />601 N. Webb Road, Grand
<br />23 IMMEDIATE CAUSE
<br />Island, Nebraska 68803 -4050
<br />PART
<br />)ENTER ONLY O CAUS PE
<br />LINE FOR lal. Ib). AND Icp
<br />Interval between onset and death
<br />r E �EATH130
<br />b
<br />;SI nature and Tiee ►
<br />.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />'1 0
<br />DUE 0 OR AS A CONSEOUENCF OF
<br />�/L NKNOWN
<br />X ❑ YES Np
<br />_ (ol 10 y 1
<br />iDUE TO. OR AS A NSEOUENCE �-
<br />_
<br />4
<br />- --j
<br />Interval between o sel and death
<br />--
<br />z REGISTRAR
<br />Interval between onset and de..lh
<br />L_— icl
<br />68803
<br />Faidley Ave., Grand Island, NE
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />PAHI 111 IF FEMALE. WAS THERE A m AUTOPSY
<br />l
<br />25 WAS CASE REFERRED TO
<br />APREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONEIA9es
<br />26a 2Gb
<br />t0 -Sa) Yl o tYes L I No LV
<br />�NIEDIC
<br />I X Yes No
<br />DATE OF INJURY /MO.. Day Vr/ 26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />-
<br />Acadenl Fj Undetermined I -
<br />M
<br />Swcide ❑ Pendinq 26e INJURY AT WORK 26f PLACE OF INJURY - qt home. farm. street. factory 26g. LOCATION STREET Jq q F.D. NO. CITY OR TOWN
<br />otlice buo ing, etc (Specify) STATE
<br />L�Homicide Investigation Yes ❑ No ❑
<br />4— _
<br />27a. DATE OF DEATH iMo.. Dav Yr.) w 28a. DATE SIGNED (Mo.. Day 28b TIME OF DEATH
<br />27b DATE SIGNED /MO Da Y.; H _ M
<br />or Y 27c TIME OF DEATH > y 28d. PRONOUNCED DEAD !Hour!
<br />a / 28c PRONOUNCED DEAD IMn Da. »I l S"/ 6% X � s M 9 -�o e best of my knowledge death Cu etl at ih Tine. date and place and due to the ° M
<br />sets) stated. 0 28e. On Trio basis of eMaminauon and or Investlgauon, In my opinion death occurred at
<br />• �� ° the time. date and place and due to the causels) stated.
<br />_
<br />Three (3), Hidden Lakes Subdivision Number Seven, Hall County, Nebraska.
<br />r�l
<br />IS, nature and Title) ►
<br />29 DID TOBACCO USE CONTRIBUTE
<br />❑YES ❑
<br />r E �EATH130
<br />;SI nature and Tiee ►
<br />.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTEDI
<br />,(- NO
<br />�/L NKNOWN
<br />X ❑ YES Np
<br />❑ YES L�NO
<br />31 NAME AND A DD RESS.pF CERTIFIER IPHYSICIAN, CORONER$ PHYSICIAN
<br />OR COUNTY ATTORNEY (Type or Pnnt /,
<br />--
<br />z REGISTRAR
<br />C� U 0,
<br />Q F ►� C 2116 W.
<br />68803
<br />Faidley Ave., Grand Island, NE
<br />32b DATE FILED BY REGISTRAR /MO. Day. 1,
<br />JAN 2 72000
<br />Three (3), Hidden Lakes Subdivision Number Seven, Hall County, Nebraska.
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