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<br />STATE OF NEBRASKA
<br />202009039
<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 I RECQRD-ONFJLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAllSl'/CS4EcFION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />2007
<br />20201102561
<br />APR 0 3 ASSISTANT stArEoroistitliR
<br />LINCOLN, NEBRASKA HEALTF ±4ND_HUMr) ` rt
<br />TANL0*:-
<br />•
<br />STATE OF NEaRASEA• DEFARTW T-OF)EALTB AND HUMAN SERVICES
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />, DECEDENT • NAME For NUKE LAST
<br />Hilda Mark Cba■Iberli■
<br />7 SEX
<br />Female
<br />3 OA':`OfDEATH .ttv26 Ow YANA —
<br />April 2*, 2494
<br />A CO, AND STATE OA WPW erM/AUSA ropy.
<br />Breath, Arkansas
<br />So AGE -Los kAs,
<br />on' 75
<br />UNDER,YEAP
<br />UNDER, DAY
<br />• DATE OP WITH sow. 13w Ivan
<br />Jane 39* 1928
<br />Sg EPOS I OATS
<br />x HduRS MFFS
<br />7
<br />aummr-
<br />As PLACE OF DEATH I�
<br />HOSPITAL 0 HUMAN OTHER �I Nurbng HO.Ie
<br />a EP OIANMO O RA.Atrre
<br />MI FACILITY. NMR. awls .**AR gwosootwwwaABIF1
<br />T.y Square Care Center
<br />0 DOA 0 Oar 'SAW
<br />k CIT , TOWN OP LOCATION OF DEAD. r •e M1S16 CITY LOADS
<br />Grand Woad I
<br />1 via Ik Na
<br />M COUNTY OF DEATH
<br />Hall
<br />M RESIDENCE - STATE ' As COUNTY
<br />Nebraska Mall
<br />CITY TOWN OR LOCATION
<br />Grid Wand
<br />So STREET AND WOOER aral0f20 Cour S. NSIOECTY LAWS
<br />1998 W let St., 68M3 I« ,�. ❑
<br />i Y
<br />,e A...0...Bare. A, 10 Ha. ~. I11 ANCESTRY to• EY/, Woe -an GM,MM OD
<br />MilIAllifitican
<br />MARRIED MAIM D
<br />TEM�0 �„(is
<br />■
<br />�'7
<br />WIDOWED
<br />DIVORCED
<br />13 NAME OFSPOUSE it roe PMrIY�,v MAW
<br />Me^_ Dwight Chamberlin
<br />145 USUAL OCCUPATION Ter wok, per. Moo demgmaw
<br />iA0 KIND OF SLIMNESS INDUSTRY EDUCATION ^4,EM
<br />fISOAC,M
<br />��pp��yAI�EM�
<br />E blifil 1lillli
<br />Oh WOO edI10NEP4
<br />/�
<br />Own Here , Esitip, d SEcanEMY ,0 ,221 cow n.A M b•,
<br />Ernest
<br />J.
<br />IT MOTHER FIRST
<br />Etta
<br />May
<br />MAIDEN SUIINAAIE
<br />Pbi Ups
<br />tE WAS DECEASED EVER IN US ARMED FORCES',
<br />IYk_'L= a UNI I I 10 Yoe •rW w we 0UEP d OMNMI
<br />t Is, INFORMANT NAME
<br />Melvin Dwight Chamberlin
<br />tb INFORMANT MALNG ADDRESS ,STREET ORRF 0 NO. CITY OR TOWN STATE 291
<br />1998 W 1st St., Graad Wend, Nebraska 68893
<br />20 EMBALMER • SIGNATURE
<br />\ / 1254
<br />Haase
<br />21a MET1400 OF DISPOSITION
<br />ItDAN 0 Removal
<br />DOSHIBMIAM,
<br />210 DATE
<br />05/03/2004
<br />21e CEMETERY OR CREMATORY NAME
<br />Mason City Cemetery
<br />210 CEMETERY OR CREMATORY LOCATION
<br />Mason City, Nebraska
<br />CITY OR TOWN
<br />22b 220 FUNERAL HOME ADDRESS (STREET OR RFD NO CITY OR TOWN STATE 2PI
<br />3213 W Marti Frsat St Grand Wand, NE, 68883
<br />STATE
<br />23 RBAEOIATE CAUSE
<br />PART
<br />DUE TO. OR AS A CONSEOUENCE OF
<br />la
<br />TENTER ONLY ONE CAUSE PER UNE FOR 'a, IMI AND ICE
<br />O.M OWIIMMMUMaroower
<br />ETIrV V'7
<br />D•MvM D.NRIM aro Ile maw
<br />DUE TO OR AS A CONSEQUENCE OF
<br />ICI
<br />w..., bMUSSl onistaM gear'
<br />PART OTHER SIONWICIWT CONDITIONS • Commons Cr6Orao b own 0w 0M onM Pomo
<br />2Ea i 210 DATE OF INJURY /ON D. gJ W. HOUR OP INJURY
<br />O Acucar* ❑ Wwl.rmvMg
<br />O S.eae 0 WHOM ! DM INJURY AT WORK
<br />❑ Myoma. Yo0/90 , YN N0 []
<br />27. DATE OF DEATH ,AA, Ow Fe
<br />q .t toy
<br />2T0 DATE WONED Mb OIr
<br />5L5101
<br />270 To a.Mdmpk
<br />e.IIIMfr riled
<br />,S,q,MA and Tl, .
<br />IPART NI IF FEMALE WAS THERE A 1 21 AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS',
<br />I 1ADN 10 -SEI Yes a F. Q Yea
<br />Wg DESCRIBE HOW AA.URY OCCURIEO
<br />No I/V
<br />ES WAS CASE REFERRED TO MEDICAL
<br />EXAMNER OR CORONE
<br />Y.. ❑ No�
<br />2M PmACE OF ILAIPY N IgM.
<br />MNr tadary 2E9 LOCATION STREET OR RF 0 NO CITY OR TOWN STATE
<br />Yr, 127c TIME OF DEATH
<br />I aft eth
<br />d,.O, OCcurca ■ee MM. Mei ane MICA PM nue ID Nle
<br />211 IOD TOBACCO USE CONTRIBUTE TO rHRE DEATH,
<br />A
<br />Eg
<br />2EA DATE SIGNED Alb Der Yr ; 2ED TIME OF DEATH
<br />M
<br />PRONOUNCED DEAD :MD Dale. r.r
<br />2b PRONOUNCED DEAD 1M040/
<br />3 $I ,S 2M On we Wood .Arn+r/M aM1 oeY.S.g.W.n. m KM W non 1NI1 mound ••
<br />ihsM MM. dw.M Om owl nue b Nle alel.ri ribM
<br />r IS9„MA. alga TI.I ►
<br />YES X NO 0 UNKNOWN
<br />3E. HAS ORGAN OR TISSUE DONATION SEEN CON&OERED'
<br />0 YES
<br />E1'.r NO
<br />300 WAS CONSENT GRANTED,
<br />YES
<br />31 NAME AND ADDRESS OF CERTIFIER ,PHYSICIAN. CORONER S PHYSICIAN OR COUNTY ATTORNEY, Two, PNET
<br />Anne K. Morse, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />
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