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� C n S 1 0 CD <br />m N <br />D y, z m <br />A CA c �° o 0 <br />v s M <br />D m O <br />C.J1 co <br />. p <br />\ s CA C.J Q <br />GI) <br />r <br />0 <br />H <br />N <br />W <br />r <br />0 <br />n <br />x <br />N <br />Q <br />G� <br />z <br />txj <br />W <br />En <br />C <br />W <br />0 <br />H <br />G <br />H <br />z <br />x <br />r <br />r <br />Ci <br />z <br />3 <br />z <br />W <br />En <br />x <br />WHEN THIS COPY CARR ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HL&AK'SEIi1Ro¢S <br />SYSTEK IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO41lif/ "N MI. <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_ l=am_ '1 - N:IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE _- <br />3/5/2004 200402563 ` <br />LINCOLN, NEBRASKA HEALTH ANQ#IBMAN-SE T SxMW _ <br />STATE OF NE_ BRASKA- nEPART_MEN_T OF HEALTH AND HUMAN W RT <br />Amended March 5, 2004 vrrAi sTKrwTlcs = n ^ O Z q <br />CERTIFICATE OF DEATH ___ _ U'+ 1 <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX; .. 1 <br />3, DATE OF DEATH /Month. Day. Year) <br />William Glee Arnall <br />Male " ` <br />anaary 31, 20M <br />4. CITY AND STATE OF BIRTH td not in U.S.A. name combo <br />Sa. AGE - Last Birthday <br />UNDER t YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /M sill. Day. Year) <br />Omaha, Nebraska <br />(Yrs.) 72 5b. <br />MOS. I DAYS <br />5c. HOURS' MINS. <br />June 13, 1931 <br />7. SOCIAL SECURRTTIIY�NUMBER <br />8a. PLACE OF DEATH <br />506-28 -5565 <br />HOSK AL Inpatient OTHER: Nursing Home <br />ER Outpatient Resldance <br />1 8b. FACILITY -Name (Hnot insb'hMon, give street and rnumber) <br />Wedgewood Care Center <br />1 <br />❑ DOA other (Specdvn <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Sid. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />IK 11 <br />all <br />Ves No <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CRY. TOWN OR LOCATION 6TTREET AND NUMBER tlncluuWg 1po Coda/ <br />U <br />9e. INSIDE CITY UNITS <br />Nebraska <br />all <br />rand Island E 19th St., 68MI <br />1:1 <br />Y--v N, <br />110. RAACE$- (e.g, White. Black. American Indian. <br />11. ASNCCcESTRY (e.g.. Italian. Mexican, German, etc) <br />12 ] MARRIED ❑ WIDOWED <br />`jam <br />13. NAME OF SPOUSE Ill wile. give Malden name) <br />WfilArcfry) <br />Ge"MIln <br />NEVER DIVORCED <br />Verna M. Frandson <br />14a. USUAL OCCUPATION IGme kind of work done drake most 14b. KIND OF BUSINESS INDUSTRY - <br />15. EDUCATION (Specify only hift* grade completed( <br />Cle'A' � /ih, even ifreftmol Broad - <br />11LL Eletwntary or Secondary 10 -121 College, 11 -4 or 5 -1 <br />16. FATHER - NAME FIRST MIDDLt LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Berhl (NM Arnall <br />Sara L. Rush <br />1& WAS DECEASED EVER IN U.S. ARMED FORCES? <br />1 INFORMANT -NAME <br />l�es. no. or wk.) (8 yes. give war and dates of serviced <br />o <br />Verna M. Arnall <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE LP) <br />507 E 19th St., Grand Island, NE 68801 <br />20. EMS ER - SIGNATURE 8 LICENSE N0. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />' 7al <br />06/2004 <br />othenburg City Cemetery <br />FUNERAL - NAM <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />ine FuneratHome <br />Cremation Donation <br />othenburg, Nebraska. <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />213 W North Front St Grand Island, NE, 68803 <br />21 IMMEDIATE CAt4SE ENTER 1L/Y�,pNE CAUSE PER LINE FOR la). (b). AND (c) I Interval between onset and death <br />PAR; // <br />/� �jJ <br />r��(C <br />4--?' ! / .4/// <br />J lI/. II /'r r v/ <br />l 5 <br />DUE TO, OR AS A CONSEQUENCE OF I Interval belwaen onset and death <br />I <br />I <br />(bl <br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death <br />I <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to ft death but not related PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART - PREGNANCY <br />�" /t"�✓ �� <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />+� (Ages <br />10 -54) Yea No <br />yes NO <br />Yes No <br />26a. <br />26b. DATE OF INJURY fAth. Day. Yr.) <br />26c. HOUR OF INJURY <br />HOW INJRY OCCURRED . <br />Accident ❑ Undetermined <br />7,26d.'DESCRIBE <br />Suicide ❑ Pending • <br />26e. INJURY AT WORK <br />26f. PLACE oaiINJURY ; ,farm, street factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes 0 No <br />olfic bw . <br />) <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED 1W. Day. Yr.; <br />28b. TIME OF DEATH <br />January 31, 2004 <br />M <br />g <br />27b. DATE SIGNED (MO.. Day. Yr.) <br />27c. TIME OF DEATH <br />278c. PRONOUNCED DEAD tMo.. Day, Yr.1 <br />28d. PRONOUNCED DEAD (Hourl <br />" <br /><� <br />February 5.;'' 2;0 <br />P.M. <br />10 : 00 <br />M <br />8 <br />.2 <br />27d. To the lees of my know) ' r date plate and due to the <br />28e. On the basis of examinatbn aM,or investigation, in my opinion death occurred at <br />cause(sl stated. J.:1, <br />` <br />the fime, date and and due to the caused stated. <br />� J - <br />r z �jti(,J <br />- <br />place <br />(Signature and Title � r <br />(Signature and Title ) ► r <br />29. 010 TOBACCO USE CONTRIBUTE TO /HE DEATH? - 30.a <br />HAS ORGAN OR TISSUE DONATION BEEI*CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />YES //NO UNKNOWN <br />YES Q NO <br />1:1 , YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print/ <br />William J. Lawt n M.D. 241#4 West F Island, NE 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo. Day. Yr.) <br />FEB <br />112004 <br />11 - <br />