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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 !f CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REQ001 f�it lN/TH ,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTCI060f- 115
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =
<br />DATE OF ISSUANCE
<br />JAN 312000 200008633 AS -
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN ( i] fIJPJRT
<br />VITAL STATISTICS -_
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month. Day. Year(
<br />Verleen V. Caulkins
<br />n C)
<br />January 16, 2000
<br />4, CITY AND STATE OF BIRTH 11 {not in U.S.A.. name country)
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />rn
<br />16. DATE OF BIRTH Da(y]. Year)
<br />MO' I DAV'
<br />Sc.HOURS' MINS
<br />Clay County, Nebraska
<br />fYrs.) 88 5b.
<br />O
<br />A(Month.
<br />July 29, 1711
<br />7. SOCIAL SECURTtV NUMBER
<br />8a. PLACE OF DEATH
<br />506 -30 -2569
<br />n
<br />HOSPITAL. lid Inpatient OTHER [] Nursing Home
<br />-- - --
<br />-
<br />ER Outpatient El Residence
<br />8b. FACILITY - Name (ltnolms(Mufgn. givesheetandnumW
<br />'n
<br />m U)
<br />8c. CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island Yes ® No F-1
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9D. COUNTY
<br />=
<br />D
<br />9e INSIDE CITY LIMITS
<br />_
<br />Hall
<br />Grand Island
<br />804 N. Boggs #206, 688
<br />3Yes ® No
<br />CO
<br />n. ANCESTRY le.g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE f f wile. give maiden name)
<br />etc.) tSpecity) White
<br />($Petty) American %
<br />MARER DIVORCED
<br />Robert Caulkins
<br />14a USUALOCCUPATIONYYIlGivelktihdot work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />1 15. EDUCATION )Specify only highest grade completed)
<br />ofworbngli/e even'p"dl
<br />Bookkeeper
<br />M
<br />U3
<br />16. FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Whitlake 1
<br />Clara Korgan
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />_
<br />19a. INFORMANT -NAME
<br />Sterling Caulkins
<br />19b INFORMANT MAILING ADDRESS 'STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />103 Canyon Dr., Phillips, NE 68865
<br />20. EMB LMER - SIGNATURE 8 LICENSE NO 93 �/
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />®Burial Removal
<br />Jan. 19, 2000
<br />Westlawn Memorial Park
<br />-22a FUNERAL OME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑ Crew ❑ Donation
<br />Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />1123 West Second, Grand Island, NE 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at. (b). AND (c)) Interval between onset and death
<br />PART I J� J z it It�� I4�•�' ���
<br />C /a,
<br />DUE TO, OR AS A Co N /EOU�ENCE OF Interval between onset and death
<br />(bl f r✓ /",4/
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />-i
<br />-1 M,
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER+
<br />(Ages
<br />10 -541 Yes No
<br />Yes No X
<br />Yes F-] No
<br />rn
<br />26b. DATE OF INJURY (MO.. Day. Yr./
<br />26c. HOUR OF INJURY
<br />CD
<br />Accident Undetermined
<br />M
<br />Su,ade Pending
<br />26e, INJURY AT WORK
<br />26'. PLACE QF. INJURY - At home, farm. street. factory
<br />o ibe bu1lding, etc (Specify)
<br />�'•�
<br />1 � Homicide Investigation
<br />Yes No
<br />❑ Q
<br />�7
<br />1�
<br />�j "
<br />CD
<br />CD
<br />>
<br />M
<br />r,
<br />-
<br />TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day. Yr I
<br />26d. PRONOUNCED-DEAD (Noun
<br /><
<br />it,o
<br />'o
<br />�g
<br />M
<br />z
<br />M
<br />a
<br />me da ca due o the
<br />r
<br />co
<br />O
<br />cause's) stated.
<br />the ume, date and place and due o the cause's) stated.
<br />(Signature and Tide
<br />r
<br />(S ture and Tide
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />129
<br />YES NO El UNKNOWN
<br />El YES (T} NO
<br />YES NO
<br />Cl)
<br />David Colan M.D. 729 N. Cust r, Grand s nd, NE 68803
<br />M
<br />32b. DATE FILED BY REGISTRAR (Md. Day. YrJ
<br />X
<br />JAN 2 6 2000
<br />�
<br />Cn
<br />WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 !f CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REQ001 f�it lN/TH ,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTCI060f- 115
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =
<br />DATE OF ISSUANCE
<br />JAN 312000 200008633 AS -
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN ( i] fIJPJRT
<br />VITAL STATISTICS -_
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month. Day. Year(
<br />Verleen V. Caulkins
<br />Female
<br />January 16, 2000
<br />4, CITY AND STATE OF BIRTH 11 {not in U.S.A.. name country)
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH Da(y]. Year)
<br />MO' I DAV'
<br />Sc.HOURS' MINS
<br />Clay County, Nebraska
<br />fYrs.) 88 5b.
<br />O
<br />A(Month.
<br />July 29, 1711
<br />7. SOCIAL SECURTtV NUMBER
<br />8a. PLACE OF DEATH
<br />506 -30 -2569
<br />n
<br />HOSPITAL. lid Inpatient OTHER [] Nursing Home
<br />-- - --
<br />ER Outpatient El Residence
<br />8b. FACILITY - Name (ltnolms(Mufgn. givesheetandnumW
<br />a St. Francis Medical Center
<br />DOA Other ISpecdvl
<br />8c. CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island Yes ® No F-1
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9D. COUNTY
<br />9c. C� ITYY.. TOWN OFiLOCATION
<br />9d. STREET AND NUMBER (Including Zip coda!
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />804 N. Boggs #206, 688
<br />3Yes ® No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />n. ANCESTRY le.g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE f f wile. give maiden name)
<br />etc.) tSpecity) White
<br />($Petty) American %
<br />MARER DIVORCED
<br />Robert Caulkins
<br />14a USUALOCCUPATIONYYIlGivelktihdot work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />1 15. EDUCATION )Specify only highest grade completed)
<br />ofworbngli/e even'p"dl
<br />Bookkeeper
<br />Auto Service
<br />Elementarrj r Secondary (0 -12) Collage (1 4 or 51I
<br />GG 1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Whitlake 1
<br />Clara Korgan
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />_
<br />19a. INFORMANT -NAME
<br />;Yes, no or un1t fit yes gne war and dafus of services)
<br />No
<br />Sterling Caulkins
<br />19b INFORMANT MAILING ADDRESS 'STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />103 Canyon Dr., Phillips, NE 68865
<br />20. EMB LMER - SIGNATURE 8 LICENSE NO 93 �/
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />®Burial Removal
<br />Jan. 19, 2000
<br />Westlawn Memorial Park
<br />-22a FUNERAL OME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑ Crew ❑ Donation
<br />Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />1123 West Second, Grand Island, NE 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at. (b). AND (c)) Interval between onset and death
<br />PART I J� J z it It�� I4�•�' ���
<br />C /a,
<br />DUE TO, OR AS A Co N /EOU�ENCE OF Interval between onset and death
<br />(bl f r✓ /",4/
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER+
<br />(Ages
<br />10 -541 Yes No
<br />Yes No X
<br />Yes F-] No
<br />26a.
<br />26b. DATE OF INJURY (MO.. Day. Yr./
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Su,ade Pending
<br />26e, INJURY AT WORK
<br />26'. PLACE QF. INJURY - At home, farm. street. factory
<br />o ibe bu1lding, etc (Specify)
<br />26g. LOCATION STREET OR R F.D. NO CITY OR TOWN STATE
<br />1 � Homicide Investigation
<br />Yes No
<br />❑ Q
<br />27a. DATE OF DEATH (Mo. Day Yr.)
<br />28a. DATE SIGNED (Mo_ Day. Yr.l
<br />281b TIME OF DEATH
<br />>
<br />M
<br />52
<br />27b DATE SIGNED (Mo.. Day Yr.) 27c.
<br />TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day. Yr I
<br />26d. PRONOUNCED-DEAD (Noun
<br /><
<br />it,o
<br />'o
<br />�g
<br />M
<br />z
<br />M
<br />27d. To the best of my knowledge. ath tuned at the
<br />me da ca due o the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />2
<br />Sc �°
<br />° a
<br />cause's) stated.
<br />the ume, date and place and due o the cause's) stated.
<br />(Signature and Tide
<br />(S ture and Tide
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />129
<br />YES NO El UNKNOWN
<br />El YES (T} NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEVI (Type or P-11
<br />David Colan M.D. 729 N. Cust r, Grand s nd, NE 68803
<br />32a REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Md. Day. YrJ
<br />X
<br />JAN 2 6 2000
<br />i
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