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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTMAY40 HU0 <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ANOQW 4 <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATl"O*1 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE f <br />APR 4 LINCOLN, NEBRASKA <br />200010635 HEALTH A SW S STATE <br />MANRV,� <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANES,�1 <br />VITAL STATISTICS - - <br />CFRTIFICATF nF nFA rcr <br />i <br />O <br />C� <br />M -) <br />rn C� <br />C-0 <br />Ca <br />lIS <br />7'dN <br />9 SUPPORT <br />C-> Cn <br />o --I <br />C > <br />M <br />� o <br />O -n <br />-TT z <br />-C M <br />D co <br />r _-C <br />r n <br />D <br />CAI <br />Cn <br />a <br />CD <br />CD <br />CL <br />O W <br />N <br />N <br />O <br />O <br />O CD <br />O y� <br />W <br />Un <br />,1. DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX - - - -- <br />3. DATE OF DEATH )Month Day Year) <br />Martin Evald Carlson <br />' <br />male I March 23 2000 <br />4 CITY AND STATE OF BIRTH ///norm USA.. name counlryl Sa. AGE - Last Birthday I UNDER 1 YEAR <br />UNDER 1 DAV 6. DATE OF BIRTH tMohln. Day. Year) <br />(Yrs.I Sb. MOS I DAYS <br />Sc. HOURS' MINS <br />aronville Nebraska 94 1 <br />D <br />7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH <br />-- <br />HOSPITAL. 0 Inpatient OTHER ❑ Nursing Home <br />22 -22 -2643 -_ - -- <br />m <br />T <br />En <br />EXAMINER OR CORONER] <br />Other,Specdvi <br />Bic . CITY. TOWN OR LOCATION OF DEATH <br />Bid INSIDE CITY LIMITS <br />Be COUNTY OF DEATH -- <br />Grand Island ____[Grand <br />Yea kl Ne ❑ <br />Hall <br />26d. DESCRIBE HOW INJURY OCCURRED <br />9a. RESIDENCE -STATE <br />9b. COUNTY <br />= <br />v <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />4216 Utah Ave. <br />Yes No <br />10. RACE - (e.g., While. Black. American Indian. <br />ISpeclfyl <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc1 <br />r) <br />❑ WIDOWED <br />13 NAME OF SPOUSE rl/ wde. give maiden name) <br />etc.) <br />White <br />(Specify) <br />American <br />X <br />DIVORCED <br />Blanche Johnson <br />14a. USUAL OCCUPATION /Give kindo! work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />_ <br />15 EDUCATION (Specify only highest grade completetll <br />d eorkrrrg life. even it reared) <br />t <br />_ <br />Elementary or Secondary 10 -121 College n 4 0 �- <br />16. FATHER - NAM FIRST MIDDLE LAST <br />17-MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Carl Anton Carlson <br />Clara <br />Monson <br />fill WAS DECEASED <br />EVER IN U S. ARMED FORCES? 19a. INFORMANT -NAME <br />- - - -- <br />(Yes, no or unk.) <br />(If yes. give war and dates of services) <br />es <br />I 4�_ Blanche Carlson <br />,19b INFORMANT MAILING ADDRESS (STREET OR R F D NO, CITY OR TOWN, STATE. ZIP) <br />- --" <br />4216 Utah Ave. Grand Island, NE. <br />68803 <br />20. MBALMER - SIG RE &LICE NO 21 a. METHOD OF DISPOSITION 21b. DATE <br />211 CEMETERY OR CREMATORY NAME <br />%} <br />7 iD Burial ❑ Removal <br />Palmer C em e t e r <br />22a FUNERAL HOME - AM 21d CEMETERY <br />OR CREMATORY LOCATION CITY OR TOWN STATE <br />TF <br />❑ Cremation ❑ Donation <br />❑ YES NO ❑ UNKNOWN <br />All Faiths Funeral Home <br />Palmer Nebraska <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTMAY40 HU0 <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ANOQW 4 <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATl"O*1 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE f <br />APR 4 LINCOLN, NEBRASKA <br />200010635 HEALTH A SW S STATE <br />MANRV,� <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANES,�1 <br />VITAL STATISTICS - - <br />CFRTIFICATF nF nFA rcr <br />i <br />O <br />C� <br />M -) <br />rn C� <br />C-0 <br />Ca <br />lIS <br />7'dN <br />9 SUPPORT <br />C-> Cn <br />o --I <br />C > <br />M <br />� o <br />O -n <br />-TT z <br />-C M <br />D co <br />r _-C <br />r n <br />D <br />CAI <br />Cn <br />a <br />CD <br />CD <br />CL <br />O W <br />N <br />N <br />O <br />O <br />O CD <br />O y� <br />W <br />Un <br />,1. DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX - - - -- <br />3. DATE OF DEATH )Month Day Year) <br />Martin Evald Carlson <br />' <br />male I March 23 2000 <br />4 CITY AND STATE OF BIRTH ///norm USA.. name counlryl Sa. AGE - Last Birthday I UNDER 1 YEAR <br />UNDER 1 DAV 6. DATE OF BIRTH tMohln. Day. Year) <br />(Yrs.I Sb. MOS I DAYS <br />Sc. HOURS' MINS <br />aronville Nebraska 94 1 <br />November 05 1905 <br />7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH <br />-- <br />HOSPITAL. 0 Inpatient OTHER ❑ Nursing Home <br />22 -22 -2643 -_ - -- <br />8b. FACILITY - Name /Il not msaruhon, give street and number) ❑ ER Outpatient ❑ Residence <br />St. Francis Medical Center ❑ DOA ❑ <br />EXAMINER OR CORONER] <br />Other,Specdvi <br />Bic . CITY. TOWN OR LOCATION OF DEATH <br />Bid INSIDE CITY LIMITS <br />Be COUNTY OF DEATH -- <br />Grand Island ____[Grand <br />Yea kl Ne ❑ <br />Hall <br />26d. DESCRIBE HOW INJURY OCCURRED <br />9a. RESIDENCE -STATE <br />9b. COUNTY <br />TOWN OR LOCATION <br />9d. STREET AND NUMBER Including Zip Code/ <br />6803 <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />4216 Utah Ave. <br />Yes No <br />10. RACE - (e.g., While. Black. American Indian. <br />ISpeclfyl <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc1 <br />12.0 MARRIED <br />❑ WIDOWED <br />13 NAME OF SPOUSE rl/ wde. give maiden name) <br />etc.) <br />White <br />(Specify) <br />American <br />NEVER <br />MARRIED <br />DIVORCED <br />Blanche Johnson <br />14a. USUAL OCCUPATION /Give kindo! work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />_ <br />15 EDUCATION (Specify only highest grade completetll <br />d eorkrrrg life. even it reared) <br />t <br />_ <br />Elementary or Secondary 10 -121 College n 4 0 �- <br />16. FATHER - NAM FIRST MIDDLE LAST <br />17-MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Carl Anton Carlson <br />Clara <br />Monson <br />fill WAS DECEASED <br />EVER IN U S. ARMED FORCES? 19a. INFORMANT -NAME <br />- - - -- <br />(Yes, no or unk.) <br />(If yes. give war and dates of services) <br />es <br />I 4�_ Blanche Carlson <br />,19b INFORMANT MAILING ADDRESS (STREET OR R F D NO, CITY OR TOWN, STATE. ZIP) <br />- --" <br />4216 Utah Ave. Grand Island, NE. <br />68803 <br />20. MBALMER - SIG RE &LICE NO 21 a. METHOD OF DISPOSITION 21b. DATE <br />211 CEMETERY OR CREMATORY NAME <br />%} <br />7 iD Burial ❑ Removal <br />Palmer C em e t e r <br />22a FUNERAL HOME - AM 21d CEMETERY <br />OR CREMATORY LOCATION CITY OR TOWN STATE <br />TF <br />❑ Cremation ❑ Donation <br />❑ YES NO ❑ UNKNOWN <br />All Faiths Funeral Home <br />Palmer Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO .CITY OR TOWN. STATE, ZIP) <br />-- - <br />2929 South Locust Grand Island, Nebraska 68801 <br />PART <br />DUE TO, OR AS A CONSEQUENCE OF <br />L <br />Interval between onset ann nean <br />DUE TO.OR AS A CONSEQUENCE OFD <br />Imervat between onset eoc J6al:. <br />Icl <br />OTHER SIGNIFICANLCONDITIONS - ondilions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />II C� Q _ ZJ /.A�., plif'p/ /L /.JP PREGNANCY <br />Q/ <br />IN THE PAST 3 MONTHS? <br />�24 <br />EXAMINER OR CORONER] <br />��JtVV`a '(`In'vn,K' <br />1. <br />(Ages 10 -54) Yes No <br />Yes No <br />Vey NO <br />26a_ <br />DATE OF INJURY W. Day. Yc) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident � Undetermmetl <br />M <br />Suicide Pending <br />26e INJURY AT WORK <br />26f. PLACE OF INJURY - At home, farm. street factory <br />o ce building, etc / Speciy) <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes No ❑ <br />27a. DATE OF DEATH /MO. Day Yc/ <br />2Ba. DATE SIGNED (MO.. Day n) <br />28b TIME OF DEATH <br />_ <br />3 <br />$ <br />M <br />i <br />g <br />27b. DATE SIGNED (MO. Day. Yr) <br />3 -3o�ov <br />7c TIME OF DEATH <br />:y-D <br />> <br />c > <br />2Bc. PRONOUNCED DEAD /MO. Day. Yrl <br />28d. PRONOUNCED DEAD IHOUrI <br />8 <br />M <br />8 <br />3 -O <br />M <br />27d. To the best of my knowledge. at red at the time, date and place and due to the <br />28e. On the basis of examination and or invesugaoon, in my opinion death occurred at <br />causefs) stated. ^ <br />(Signature and Title) j <br />° B <br />, the time, date and place and due to Me causelsl stated. <br />(Signature and TMe <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED' <br />❑ YES NO ❑ UNKNOWN <br />❑ YES NO <br />❑ <br />-W <br />IF40 <br />YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type b' Ponry <br />L-barA r I i . D o2 ! I Ce F <br />d( 0 Qa n d s gg,�_3 <br />32A REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.D y I <br />.,I <br />qi . Qa_(! t \ L L 1' k\c,% 1A�C ( I l r IkA\ .,%I c; .,% 'A 1 . id'.1 i <br />. So <br />