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1 DECEDENT. NAME FIRST MIDDLE LAST 2 SE - - M In Everne George Darnall Male July 26, 2000 r ^ = UNDER 1 YEAR UNDER I DA 6. DATE OF BIRTH :Month. Day Year) C CD 2 C-1 01 D Sc HOURS RAINS N .fv/.1 cD C T� N 508 -05 -7816 m } —i M -< O ❑ DOA ❑ ahe- :��r,,, _ _____. �n/� VI 8e COUNTY OF DEATH Grand Island � yes 0 No ❑ Hall 9a. RESIDENCE STATE 9b. COUNTY O CD 9d STREET AND NUMBER pnauding Zrp Codel 9e INSIDE CITY LIMITS IF11-1 Hall and Island 817 W. 7th, 68801 Yes ❑X No ❑ 7 r Ca 13 NAME OF SPOUSE (it wde. give maiden name) etc .I lSoeaM White D' ❑NEVER DIVORCED MARRIED Bessie E_ Klein CD 14b KIND OF BUSINESS INDUSTRY O3 Elementary o ondary 0 12) College 1 1 or �• � �� CID Diers Motors N t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND]_ MAN SERVICES Clara Herrold July 27 000 SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/GINAL flL9'*77H aNq J M -_ -- THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA. . IS 27d To the best of my know e. M ocounetl at the I date and place antl ue to the 28e. On the basis of examination and or Investigation. m my opinion death occurred at 2 „ ,VkMH THE LEGAL DEPOSITORY FOR VITAL RECORDS. = _ causefsl stated. ° DATE OF ISSUANCE 200009062 COMER (5' nature and Title) AUG 8 2000 .i rM 29 DID TOBACCO USE CON IBUTE 10 THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' LINCOLN, NEBRll A C ❑ YES NO ❑ YES NO OF NEBRASKA- DEPARTNffiWF OF HEALH�n1�D� AS�PC7RT VITAL STATISTICS - f= CERTIFICATE OF DEATH - 1 DECEDENT. NAME FIRST MIDDLE LAST 2 SE - - " -A OF DEATH ;Moon Dal, Year, Everne George Darnall Male July 26, 2000 4 CITY AND STATE OF BIRTH df not in USA.. name country! 5a. AGE - Last Birthday UNDER 1 YEAR UNDER I DA 6. DATE OF BIRTH :Month. Day Year) Cordova, Nebraska (Y's l 91 5b MOS DAYS Sc HOURS RAINS April 28 , 1909 7 SOCIAL SEECURTIY NUMBER 8a. PLACE OF DEATH 508 -05 -7816 HOSPITAL ❑ Inoalienl OTHER ® Nu +sng Hnnle ❑ ER Outpatient ❑ ResOe,,, 6b FACILITY - Name (it notmstfdfrcn. give street and number/ St. Francis Memorial Health Center ❑ DOA ❑ ahe- :��r,,, _ _____. Sc CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand Island � yes 0 No ❑ Hall 9a. RESIDENCE STATE 9b. COUNTY 9TOW N OR LOCATION 9d STREET AND NUMBER pnauding Zrp Codel 9e INSIDE CITY LIMITS Nebraska Hall and Island 817 W. 7th, 68801 Yes ❑X No ❑ 10. RACE - fe.g.. Whne. Black. American Indian t t. ANCESTRY le .g_ Italian. Mexican. German. elcl 12. ® MARRIED ❑ Wit DOWED 13 NAME OF SPOUSE (it wde. give maiden name) etc .I lSoeaM White ISpecdyl American ❑NEVER DIVORCED MARRIED Bessie E_ Klein 14a USUAL OCCUPATION (Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Spec only highest grade completed) Elementary o ondary 0 12) College 1 1 or �• � �� d wvrkmg life. even Aretired! Auto Mechanic Diers Motors 16. FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Fred Darnall Clara Herrold 18 WAS DECEASED EVEH IN U.J. AHMEU IUHUtJ1 lua irvr Vnm HNI -iv Hnv[ (Yes no or unk) I III yes. give war and dates of services) No Bessie E. Darnall 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN STATE ZIPI 17 West 7th, Grand Island, NE 68801 EMBAL ER - SIGNATURE 8 LICENSE NO v G, ``� 21 a METHOD OF DISPOSITION 21b DATE 21 c. CEMETERY OR CREMATORY NAME Burial ❑ Remnvai Jul 29, 2000 Westlawn Memorial Park a. FUN RAL HQ E - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes ❑ Cremation ❑ Donation Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island; NE. 68801 23. IMMEDI E (ENTER ONLY ONE CAUSE PER LINE FOR IaI. Ibl. AND Icll Interval between onset ano deal" PART / 1 al DUE TO, OR AS A CONSEQUENCE OF Interval between onset and nealn DUE TO. OR AS A CONSEQUENCE OF Interval between onset ann dean OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART Ill IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' N � (Ages 10 -541 Yes No Yes No Yes �NO�.__ 26a 26b. DATE OF INJURY (MO.. Day Yr) 226d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined Suicide Pending 26e. INJURY AT WORK 261 oNA DuOildi INJURY - At home farm street. factory 26g. LOCATION STREET OR R F D. NO CITY OR TOWN STATE Ho—de, Investigation ❑ ❑ etc Yes No 27a. DATE OF DEATH (Mo.. Day. Yr) 28a DATE SIGNED (Mo. Dav 1`0 28b TIME OF DEATH $45 July 26,2000 a�= _ M y > ° 27b. DATE SIGNED (M... Day Yr) 27c TIME OF DEATH 28c PRONOUNCED DEAD /MO.. Day. Yr.) 28d. PRONOUNCED DEAD /H1 July 27 000 10:35am M aNq J M -_ -- STS goo 27d To the best of my know e. M ocounetl at the I date and place antl ue to the 28e. On the basis of examination and or Investigation. m my opinion death occurred at 2 o causefsl stated. ° the eme, date and place and due to the causelsl stated. (5' nature and Title) ISignature and Title) ► 29 DID TOBACCO USE CON IBUTE 10 THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' YES ❑ ❑ UNKNOWN ❑ YES NO ❑ YES NO 31. rvAMt AI'N AuuntJJ t,r eeH nr1tH Irn TJ1uAN, wnunen a rn.ai�wn vn wury I r r i i �nrvc r i r r yPCW .�� „u John A. Wagoner, Jr., �1� D. 8 #pha, Grand Island, NE. 68803 32a. REGISTRAR T% /"4* b. 32b. DATE FILED BY REGISTRAR (Mo. Day Yr1 rn !�D 4 d N a CD w A M C LEGAL: The Westerly 33 feet of Fractional Lot Three (3), in Fractional Block. Five (5), in Rollins Addition to the city of Grand :Island, Hall County, Nebraska