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\C <br />rn . <br />f-1 r •-j •° -i <br />to a Ut V <br />�•t M J tJt <br />G'T oi4 o"o <br />d1 Y tD ,C O tD <br />u a rf <br />U a '*1 3 N• <br />N �• - 'O Cr y <br />i u r�3 rJ q <br />:J ro T P. <br />v' r a ! <br />tit+arf m <br />n w to y1 <br />N CY o `?I CL <br />• D n t0 <br />h n O Fr. <br />w3 ay <br />R+ N5'r0 <br />t-9 • r+ <br />C•i �J - O fn <br />WHEN TNS COPYCARRES T14E RAISED SEAL OF THE NEBRASKA HEALTH AND Hl 1GI M SERVICES <br />SYSTEIIt R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE R"TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST!"Se"M WHO-f- <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE r/ <br />113 0 6 8 <br />MAR 2 4 1999 2 ASSISTAk STATE REdjST13M <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SElgflCES,tIYSTEII�` <br />STATE of NEBRASKA- DEPARTMENT of HEALTH AND HUMAN SERVICES FINANCE <br />V[rALSTA11MCS - <br />n1120*"IVTnAIMAI TIT;A'T'iT =- - <br />cy <br />�J <br />I. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />m <br />Carol Jean Young <br />Female <br />March 14, 1999 <br />A. CRY AND STATE OF BIRTH (Tnof h USA. mama courroBirthday 'yl <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />0. DATE OF BIRTH /Adonft D&y. Yowl <br />�4 <br />() <br />n <br />-TT <br />z <br />M,� 5j_1938 <br />l -ICi Y <br />7. SOCIAL SECURTIY NUMBER <br />M <br />� <br />N <br />:C <br />HOSPITAL paved <br />4 <br />°f-• <br />o I-+ <br />k. FACILITY -Name (Ynd kyeaiAOrl Pn+Aaref MlO MarfWd. <br />r-0. <br />CID <br />M <br />k. CITY. TOWN OR LOCATION OF DEATH d. INSIDE CRY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island, Nebraska Yaa 2 -fa ❑ <br />Hall <br />91L RESIDENCE - STATE <br />90. COUNTY <br />k. CITY, TOWN OR LOCATION <br />9e. STREET AND NUMBER /hckroTrq Z10 C00e1 <br />9e. INSIDE CRY LIMITS <br />© <br />'Hall <br />Grand Island <br />CCi7 <br />G <br />1(k RACE - (. a White. Black. Arnedean ktdlan. <br />11. ANCEBTRV 1e.9.. MUM Meaiean, dealer► owl <br />12 ®MARRIED � WIDOWED <br />/r wAe. wAv rrMid n Aww <br />stollsPeeeylWhite <br />ISPectil American <br />I <br />Z <br />N <br />14. USUAL OCCUPATION JGiw kad of cork d" dk&*v moat lab. <br />7C <br />1 S. EDUCATION <br />(SPK4 0* highest wide IX *0111e10 <br />Ele n! ff o S*c dw Io -,xl _ C~ 114 or 5•I <br />11 <br />of wv*oy e7A awn Wr~1 <br />Housewife <br />Domestic <br />�� <br />m <br />C� <br />M <br />O <br />y <br />IYea. no. or unk.l IN yes 9^ a ••+• and dates d swAcesl <br />No <br />IEdgar A. Young <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIPI <br />3 Brahma Grand Island, Nebraska 68801 <br />20. - SIGNATURE d LICENSE NO. '�L/ <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />MALMER <br />11 lgal <br />-< o <br />Grand Island City Cemetery <br />22a FLW~HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CRV OR TOWN STATE <br />fel- Butler - Geddes <br />El`""""°" ElD01i40" <br />Grand Island, Nebraska <br />22b. FL04ML HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( ' <br />1123 West Second Street Grand Island, Nebraska 68801 <br />IAMEDNATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR let. MI. AND (cll I Interval between onset and death <br />I <br />J2537;� T <br />p -Yt <br />: C <br />BA I <br />DUE TO. OR AS A CONSEOUENCE OF I IMMvsl benveen nntet -d death <br />i <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Con4ftns txrad0utlrg to the death Dut nd r~ PART NI IF FEMALE. WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />PART PREGNANCY IN THE PAST 3 MONTHS? <br />e <br />(Awes 10.511 Yes Q No vas NO 13 Yes NO <br />26a. <br />26b. DATE OF INJURY (MO.. Day. 141.1 <br />26c. HOUR OF INJURY <br />� <br />�T <br />CJ O <br />-n <br />S.da Pending <br />26e. INJURY AT WORK <br />261. PLAS E=RY IA h01)y. farm. street factory <br />�OKaYI <br />26g. LOCATION STREET OR Rf.D. NO. CITY OR TOWN ;STATE <br />❑ Homicide Investpatdn <br />Yes No ❑ <br />d�6CC <br />27a. DATE OF DEATH /Ab. Day Yc1 <br />S TT1 <br />>. Cu <br />F--A <br />°[ <br />aT <br />M <br />270. DATE SIGNED /Ab.. Day. Yrl <br />27c. TIME OF DEATH <br />2&. PRONOUNCED DEAD lMO.. Day. YrJ <br />2tld. PRONOUNCED DEAD (Hail <br />W <br />M <br />M <br />a <br />3 <br />O <br />29e. On the basis d e[anMl�bo my oDi WafO OC wilt <br />ated. <br />i D <br />uusdsl sated. <br />CU <br />the 0ma. dale and dac <br />(Signature and Title <br />nakae and Tidal <br />29. DID TOBACCO <br />USE CONTRIBUTE TO THE DEATH? <br />Cn <br />W <br />( <br />I 1 YES I I NO UNKNOWN <br />1:1 YES [1 NO <br />1:1 YES NO <br />7C <br />GJ <br />..i.> <br />Cn <br />co <br />O <br />Cn <br />WHEN TNS COPYCARRES T14E RAISED SEAL OF THE NEBRASKA HEALTH AND Hl 1GI M SERVICES <br />SYSTEIIt R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE R"TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST!"Se"M WHO-f- <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE r/ <br />113 0 6 8 <br />MAR 2 4 1999 2 ASSISTAk STATE REdjST13M <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SElgflCES,tIYSTEII�` <br />STATE of NEBRASKA- DEPARTMENT of HEALTH AND HUMAN SERVICES FINANCE <br />V[rALSTA11MCS - <br />n1120*"IVTnAIMAI TIT;A'T'iT =- - <br />cy <br />�J <br />I. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /MortNA. DAY. VW - <br />Carol Jean Young <br />Female <br />March 14, 1999 <br />A. CRY AND STATE OF BIRTH (Tnof h USA. mama courroBirthday 'yl <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />0. DATE OF BIRTH /Adonft D&y. Yowl <br />MOS. DAYS <br />t <br />x. HouRS' MINS. <br />_Watertown, South Dakota <br />rM1 5b. <br />60 <br />M,� 5j_1938 <br />l -ICi Y <br />7. SOCIAL SECURTIY NUMBER <br />Ga. PLACE OF DEATH .. _ <br />k OTHER El Nursing Home <br />504-40 -3203 <br />HOSPITAL paved <br />FK1 ER Oulpab" El Residence <br />k. FACILITY -Name (Ynd kyeaiAOrl Pn+Aaref MlO MarfWd. <br />Sf__ Francis Medical Center <br />El OOA � 001sr /SpecAyl <br />k. CITY. TOWN OR LOCATION OF DEATH d. INSIDE CRY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island, Nebraska Yaa 2 -fa ❑ <br />Hall <br />91L RESIDENCE - STATE <br />90. COUNTY <br />k. CITY, TOWN OR LOCATION <br />9e. STREET AND NUMBER /hckroTrq Z10 C00e1 <br />9e. INSIDE CRY LIMITS <br />Nebraska <br />'Hall <br />Grand Island <br />I 2613 Brahma 68801 <br />Yn ®- ❑ <br />1(k RACE - (. a White. Black. Arnedean ktdlan. <br />11. ANCEBTRV 1e.9.. MUM Meaiean, dealer► owl <br />12 ®MARRIED � WIDOWED <br />/r wAe. wAv rrMid n Aww <br />stollsPeeeylWhite <br />ISPectil American <br />I <br />NEVER DIVORCED <br />111NAMEOFSPOUSE <br />Edgar A. Young <br />14. USUAL OCCUPATION JGiw kad of cork d" dk&*v moat lab. <br />KIND OF BUSINESS INDUSTRY <br />1 S. EDUCATION <br />(SPK4 0* highest wide IX *0111e10 <br />Ele n! ff o S*c dw Io -,xl _ C~ 114 or 5•I <br />11 <br />of wv*oy e7A awn Wr~1 <br />Housewife <br />Domestic <br />tl FATHER - NAME . FIRST MIDDLE LAST - 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Herbert Benner <br />Edna Smith <br />1! WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />IYea. no. or unk.l IN yes 9^ a ••+• and dates d swAcesl <br />No <br />IEdgar A. Young <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIPI <br />3 Brahma Grand Island, Nebraska 68801 <br />20. - SIGNATURE d LICENSE NO. '�L/ <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />MALMER <br />11 lgal <br />[X Burw ❑Fw <br />m March 18, 1999 <br />Grand Island City Cemetery <br />22a FLW~HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CRV OR TOWN STATE <br />fel- Butler - Geddes <br />El`""""°" ElD01i40" <br />Grand Island, Nebraska <br />22b. FL04ML HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( ' <br />1123 West Second Street Grand Island, Nebraska 68801 <br />IAMEDNATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR let. MI. AND (cll I Interval between onset and death <br />I <br />J2537;� T <br />' (al Cardiac arrest <br />I Interval be~ ~ and deal, <br />DUE TO. OR AS A CONSEOUENCE OF I <br />I <br />BA I <br />DUE TO. OR AS A CONSEOUENCE OF I IMMvsl benveen nntet -d death <br />i <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Con4ftns txrad0utlrg to the death Dut nd r~ PART NI IF FEMALE. WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />PART PREGNANCY IN THE PAST 3 MONTHS? <br />e <br />(Awes 10.511 Yes Q No vas NO 13 Yes NO <br />26a. <br />26b. DATE OF INJURY (MO.. Day. 141.1 <br />26c. HOUR OF INJURY <br />26d DESCRIBE HOW INJURY OCCURRED <br />oAccdent o Undetermined <br />M <br />S.da Pending <br />26e. INJURY AT WORK <br />261. PLAS E=RY IA h01)y. farm. street factory <br />�OKaYI <br />26g. LOCATION STREET OR Rf.D. NO. CITY OR TOWN ;STATE <br />❑ Homicide Investpatdn <br />Yes No ❑ <br />d�6CC <br />27a. DATE OF DEATH /Ab. Day Yc1 <br />26a. DATE SIGNED (W... Day Yr I <br />2tib_ TIME OF DEATH _. <br />aT <br />M <br />270. DATE SIGNED /Ab.. Day. Yrl <br />27c. TIME OF DEATH <br />2&. PRONOUNCED DEAD lMO.. Day. YrJ <br />2tld. PRONOUNCED DEAD (Hail <br />k <br />M <br />M <br />a <br />3 <br />27d. To the Wet d my knowledge. death occurred at to Wne. data and owe and due b tlIa <br />29e. On the basis d e[anMl�bo my oDi WafO OC wilt <br />ated. <br />uusdsl sated. <br />a <br />the 0ma. dale and dac <br />(Signature and Title <br />nakae and Tidal <br />29. DID TOBACCO <br />USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.D GRANT . <br />( <br />I 1 YES I I NO UNKNOWN <br />1:1 YES [1 NO <br />1:1 YES NO <br />l III <br />