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SEP/12/2019/THU 08:33 AM Blueprint Engines FAX No, 3082341978
<br />P. 007
<br />2019,06021
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE. NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL STATISTICS SECTION( WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS,
<br />•
<br />DATE QF ISSUANCE
<br />•5/11/2004
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT -NAME
<br />I�
<br />ANLEYS. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />- HEALTH AND HUMAN N SERVICES SYSTEM
<br />STATE OF NEBRASKA- I)EFARTh1NP OI: •EEALTii AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS 04812
<br />CERTIFICATE OF DEATH
<br />FIRST MIDDLE LAST 2 SEX ,
<br />Melvin Clyde Arnold Male
<br />O. CITY AND STATE OF 810T1 /Opt r,OSA_ nam.00uWy/
<br />Norfolk, Nebraska
<br />7, SOCIAL SECURTY NUMBER
<br />50. A06 - Last Bk oi,y
<br />'76
<br />UNDER 1 YEAR
<br />UNDER t.DAY
<br />3, DATE OF DEATH /MoruA, Oay. Year/
<br />April 22, 2004
<br />55. MOS r DAYS;
<br />I
<br />5C. HOURS' MINS.
<br />505-22-9046
<br />85.'FACILITY-Name Innarm;nrurkr4 glNo siva end numbary
<br />Home: 213p W. 13th St.
<br />Os. CITY. TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />Ba. RESIDENCE -STATE B6 COUNTY
<br />Nebraska Hall
<br />10. RACE - (aµ• While. Blare. Amarlean Indian,
<br />olc l Iso White.
<br />B, DATE OF emu /Month. Day,.voad
<br />May 19, 1927
<br />On. PLACE OF DEATH
<br />HOSPITAL H . Inpellero OTHER: 0 NUr1,ng Homo
<br />ER OulDeeenl MI Re:ldo/we
<br />. .• 0 DOA 0 Other /Soc ,t I
<br />ed. INSIOE CITY LIMITS 9e. COUNTY OF DEATH .
<br />Yee ®No 0 L_. . .. Hall •
<br />AL CITY. TOWN OR LOCATION sq. STREET ANO NUMBER %IncludAp27p Code)
<br />Grand ISland .
<br />11. ANCESTRY ley.. baEen. Mollcan. 04rmen, on)
<br />ISAaciy) - .
<br />Alae=nazi
<br />14a. USUAL OCCUPATION /GA,. IrAwrofwpn* crone deny most
<br />orhrork ng I0* even Droarod)
<br />Co -Owner
<br />15 FATTIER --NAME FIRST
<br />Ned
<br />2130 W. 13th St. 68803.
<br />t2 a MAR". ❑ WIDOWED
<br />NEVER - OIVQACED
<br />145. KIND OF BUSINESS INDUSTRY
<br />MIDDLE
<br />ea. INSIDE CITY LIMITS
<br />Yea E .No a
<br />13. NAME OF SPOUSE /AwAa ¢-.e msosn 1110$
<br />Antonia -Schroeder
<br />16. EDUCATION !Specify only leanest grade complotad).
<br />Eleheniary or Seca den 1x121 001109. 11.4 at yl
<br />Canteen Vending Co. 12
<br />LAST 17. MOTHER FIRST ;MIDDLE MAIDEN SURNAME ,
<br />Arnold Margaret
<br />111. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME
<br />(Yoe. no. or unk.) le yob. Alva war aha Oakes or eervicee) `
<br />.Yes.: 6-15-45/6-5-46 . Antonia Arnold
<br />I9b, INFORMANT MAILING ADDRESS w (STREET OR R.K.O. ND: CRY OR TOWN. STATE. ZIP)
<br />Grand Island, NE. 68803'
<br />2130 W. 13th St. ,
<br />Filter -
<br />2a EMBAUA
<br />SIGNATURE d LICENSE No. /2 S/C,
<br />,ata. FU -. •LHOME -NAM
<br />Apf 111 -Butler -Geddes
<br />21e. METNOO OF 01811091TIOH
<br />Burial • Q Remove,
<br />ODemean
<br />225. FUNERAL HOME ADDRESS (STREET OR R,F,O. NO. CITY CR TOWN, STATE, ZIP)
<br />1123 West Second; .Grand Island, NE 68801
<br />N?n
<br />21b. DATE
<br />TIC. CEMETERY OR CREMATORY NAME
<br />April 27; 2004. Westlawn Memorial Park
<br />21d. CEMETERY OR CREMATORY LOCATION - CITY OR TOWN STATE
<br />Grand Island, Nebraska
<br />23. IMMEDIATE CAUSE
<br />PART
<br />Ila
<br />DUE TO, OR ASA
<br />S OUENCE0
<br />DUE TO. ORAE A CO!)SECUENCE CF:
<br />• IENTF ONLY ONE USE PER LINE FOR rap. l=), AND Lc))
<br />R.Cl\C. .,Cr�OS �S
<br />Internal between Ianedee
<br />/ mm
<br />InleNal behveen onsot end demo
<br />(CI -
<br />OTHER SIGNIFICANT CONDITIONS - Cauleone COnblbtling lo So death but not related
<br />PART
<br />II
<br />260.
<br />❑ AccMent ❑ Undetermined
<br />0 Suicide ❑ Portend
<br />❑ HonJekle Invcatigaton
<br />aeb, DATE OF INJURY
<br />25a. INJURY AT WORK
<br />Yee El NoE
<br />278. OATS OF DEATH Aro- Oay. yr.) ,
<br />/143_ Day. nI
<br />Dec. HOUR OP INJURY
<br />PART SI IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PREGNANCY INNS PAST 3 MONTHS?
<br />M
<br />(Age: 1054) Yea • No
<br />Q.. . No r,
<br />Md.DESCRIBENOW INJURY OCCURRED
<br />Yee
<br />mWlvar between Whet and deel0
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />Yaa • No
<br />261. KITE. SNMF1ng•.S.Y.)SAt; . rarm. Sroe locSoy
<br />2002 IOCATIO
<br />STREETORR.F.O.NO. CITY OR TOWN STATE
<br />April 22, 2004
<br />aF • 27b. DATE SIGNED /Mo. Dqy. YrJ
<br />S TO
<br />y11l 1E� 1
<br />' 27d. '/b Inabcslot my
<br />-;•_b__0'
<br />270. TIME OF DEAT1t
<br />Occurred at
<br />10. cau:Wbl :121e0. r
<br />6310,411'W* end Tele, • n
<br />29. 0)0 TOBACCO USE CONTRIBUTE TO THE DEATH? .
<br />• ❑ YE8
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY! 17)000rPryl'
<br />NO
<br />S. 0s •
<br />'ELY
<br />1631 M AECS
<br />E
<br />d., dam and plegia d dux to the _ ,5 /.g e 2Be. On INV a illumination and• W maeWJNlor1 M r y opinto dee, =con= e1 ma Mee. dab end dace an= due t6 S0 duestel clam&
<br />nn e� �� N ,1Slgnes00 and TAI=
<br />30.= HAS ORGAN OR TISSUE DONATION BEEN CONSI015OE0?.
<br />28a DATE SIGNED /lift. Do,. Y,)
<br />286 TIMEOF DEAN
<br />28a PRONOUNCED DEAD /Ma. Day, Yi f
<br />280. PRONOUNCED DEAD /Howl
<br />UNKNOWN
<br />YES d1 NO
<br />30.= WAS CONSENT GRANTED? (-7�
<br />YES
<br />M
<br />John J1 Cannella M.D. .729-N. Custer', Grand Island, NE. 68803.•
<br />32x. REGISTRAR I 325. OATS FILED BY REGISTRAR (Ma Da , Y,,I
<br />MAY - 3 2(16
<br />
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