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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN . DES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE6Ol THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS THE LEGAL DEPOSITORY FOR VITAL RECORDS. -,- DATE OF ISSUANCE l - OCT 302uoa 20010991 9 � ASSISTATT STATE Ql� = LINCOLN, NEBRASKA HEALTH AND HL AN, STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FiNA'iRa kRD SCg'PORT VTTAL STATISTICS = - CERTIFICATE OF DEATH ! 1 DECEDENT NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH ;MO „(h ; ),n Yrari Daniel T. Ki0y Male - October 2000 4, CITY AND STATE OF BIRTH ill noon USA name cournryl Sa AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY _2_3, _ 6. DATE OF BIRTH Month Dav Year/ Dy, Is 51b MOS I DAYS 5c. HOURS MINS Grand Island, Nebraska 61 June 21 1939 _ 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 506 42 3905 HOSPITAL ❑ Inpatient OTHER ® Nursiny Horn• - - - ❑ ER Outpatient ❑ Res�tlence 8b FACILITY Name (if nor,nstituton, give street and number) Beverly Healthcare Park_ ❑ DOA - _Place 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Ae COUNTY OF DEATH ._:-Yes -liil..N°.❑ __. -. _. 1 9a RESIDENCE STATE 9b COUNTY - - . TOWN OTT LOCATION - 9C STRE_T AND NUMBER Ito:ndrrg Zip !',del q iNSIOF C'Tv LIMITS Nebraska Hall Grand Island 610 N. Darr, 68803 Yet k] No C _ L 10 RACE - leg., White Black American Indan I 11 ANCESTRY le 9 Italian. Mexican_ German. etcl 12. [-X] MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (It wife gr✓e made,, name! etc I ISoecilyj ISoecityl White American NEVER DIVORCED MARRIED Sharon Schleichardt- — 14a USUAL OCCUPATION ;Give kmdol work done dung mosr 141 KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecity nnly mghest grade completedl of working tile. even d retmedl Truck Driver Petroleum Elementary or Secondary i0. 12) Coueq,, . 12th Grade 16. FATHER, NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME (Dec.) W. T. Kirby (Dec.) Alice NMI Birkel 18 WAS DECEASED EVER IN US ARMED FORCES IV +9a INFORMANT - NAME I Yes no or unk III yes give war and dales of services) �etnam Era Yes 1956 - 1960 Sharon Kirby 19b INFORMANT MAILING ADDRESS STREET OR R D NO OR TOWN STATE. ZIP) 1706 E. Capital Ave., Grand Island Nebraska 68801 20 EMBALMER . SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21C CFMETERY OR CHFMA I' wY NAME Service Not Embalmed ❑Burial ❑Removal Oct. 24, 2000 Central Nebraska_ Crematic _ 22a. FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCATION '':11, '.1 TOWN -ITA' Kleine Funeral Home ® Cremation ❑ DOT Gibbon, Nebraska 22b. FUNERAL HOME ADDRESS ISTREET OR R.F D NO CITY OR TOWN STATE. ZIP) 3213 West Nor 0-21 IMMEDIATE CAUSE I`EN ERpONLY ON6CAUSE PER LINE FO D Ids � Imerval belweer+ ores PART / V e— S !�1{LLi -C-n' /�siclt /.�'i`_ al � � UUt IU. UH Ab A UONStUUtNUE OF Iryervai beiween ons•,'. i . 1. use ice. vn n�ncurv�rtJUrrvcr_�n mteiv.i nelweeo ,in,.., r.. .11 OTHER SIGNIFICANT CONDITIONS Condnrons contributing to the death but not related PART 111 IF FEMALE. WAS THERE A �TOPSv S' WAS (,ASE HEF EHHE I i MEDICA, PART PREGNANCY IN THE PAST 3 MONTHS - II GXAMINf R OR COR I - (Ages 10 -54) Yes No Yes 22 v ti ❑ T26b DATE OF INJURY Mo Day 26< HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Untlet—m e] S—Ide Penoing 21, 11)11,111 AT WORK 261 PLLffiACE OF INJURY At nome farm street . factory tog LOCATION STREET OR R F D NO IT r OR TOyIN ;T .I: oce building etc Scec�lyl Homicide Investigation yes ❑ No ❑ i _ —. 27a DATE Of DEATH (MO Dav yr i 28a DATE SIGNED IMO Day Yr i l2Ab TIME OF DEATH :3%o= aw as o�= m 2jb DATE SIGNED IMO. Dav ” 2Y,p 1IME OF DEATH 28c PRONOUNCED DEAD ,Mo Day Y 2Bd. HONOUNC Ef DVAD T J bk E w x gn O z oo U V _ �V �r y M E °'r 27\7 To the best 01 my knowledge (h T�at the Ii e. ddte and lace and due !^ me ¢ 0 28e. On the basis of examination and Or invesngdtionLin my opinion nealn rrt'u «en n Causel sl slated 11 ^ ° the time date and place and due to the causeisi stated V 19gnalure and Titles ► i5i� nature and Title) ► Z9' DID TOBACCO E CONTRIBUTE HF. DEA Hn a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED^ 3db WAS CONSENT ,RANTED" T-�-� YES ❑ NO ❑ UNKNOWN ❑ YES l -I NO ( ❑ YES 31 NAME AND ADDRESS OF CERTIFIER 'PHYSICIAN, CORONERS PHYSICII OR COUNTY ATTORNEY) lTyoe or Prmli Sitki Copur MD, 211,6 West Paidley Ave. , Grand Island, Neb_1_ raska 68803 7 7—TT— _ - - -- -- - 32a REGISTRAR 321 DATE FILED BY REGISTRAR IMO. Dav rr r X U EXHIBIT "A" n