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LOT TEN (10), BLOCK ELEVEN (11), IN UNIVERSITY PLACE, A01 ADDITIOTI TO THE CITY OF
<br />GRAND ISLAND, HALL COUNTY, NEBRASKA.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEB$gSKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TEtUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STAT �1EpARTMgn' OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L-� DEP©SITORt�'VOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200402795
<br />DEC 2 7 1991 STANtiP.S, '000PE� ,,: WIRECTOR
<br />^ Jt r
<br />LINCOLN, NEBRASKA BUREAU OF V�ir�L'$TATISTICS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 12 SEX 3. DATE OF DEATH !Month. Day. Year;
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Harold Peter Speak Male 1 December 5, 1991
<br />4. CITY AND STATE OF BIRTH (N not rn USA, name cwntry)
<br />AGE Las! Blnhday
<br />t Y R
<br />6. DATE OF BIRTH ,Mon M. Day. Year)
<br />50. MOS. DAYS Sc. HOURS' MINS
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNOET.,
<br />M
<br />26C. HOUR OF INJURY
<br />Grand Island, Nebraska
<br />83
<br />April 8, 1908
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH }Y[
<br />NE
<br />C
<br />HOSPITAL. Inpatient C ER Ostpabem u DOA
<br />1 507 10 3957
<br />I OTHER ❑ Nursing Home Zj Residence :1 Other ,Speci fy )
<br />8b FACILITY - Name (N nor inson~ gore street and number)
<br />Sc . CITY, TOWN OR LOCATION OF DEATH
<br />C
<br />n =
<br />December 5. 1991
<br />. -•.S
<br />(Speciy Yes or No)
<br />I
<br />VA Medical Center
<br />Z
<br />7C
<br />Hall
<br />`-:
<br />C>
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inclding Zip Code)
<br />N
<br />Nebraska
<br />=9b
<br />Hall
<br />Grand Island
<br />215 N. Sheridan 68801
<br />M
<br />A
<br />11. ANCESTRY le.g.,ltakan. Mexican, German, etc.)
<br />12. MARRIED.NEVER MARRIED, t3.
<br />�
<br />etc.) ( specify)
<br />c n
<br />Z
<br />7C
<br />N
<br />=
<br />White
<br />Irish 0q
<br />�
<br />Opal N. Cooper
<br />M
<br />1 ♦b. KIND OF BUSINESS INDUSTRY
<br />1
<br />of working life, even d refired)
<br />Elementary or Secondary (0 -121 1 College 11 -A or 5 -)
<br />Truck Driver �'��
<br />-t o
<br />12th
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />(Dec.) Jerry J. Speak
<br />(Dec.) Anna McIntyre
<br />18. WAS DECEASED
<br />o _1`1
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />(Yes, no, or unk.)
<br />Yes
<br />(g yes, give war and dates of servdes)
<br />WWI14 /4/42- 10/26/45
<br />Opal N. S eak,221�- Sheridan,Grand Island,NE 68801
<br />20a BURIAL, Cremation,Removal,
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME
<br />20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />o T
<br />B rial
<br />= r71
<br />Westlawn Memorial Park
<br />Grand Island NE.
<br />MX ER - SIGNATURE B�NSE NO --
<br />22, FUNERAL HOME •NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />d
<br />fel- Butler - Geddes 1123 W. 2nd, Grand Island, NR-68801
<br />n C3
<br />rr
<br />M
<br />Cn
<br />LOT TEN (10), BLOCK ELEVEN (11), IN UNIVERSITY PLACE, A01 ADDITIOTI TO THE CITY OF
<br />GRAND ISLAND, HALL COUNTY, NEBRASKA.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEB$gSKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TEtUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STAT �1EpARTMgn' OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L-� DEP©SITORt�'VOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200402795
<br />DEC 2 7 1991 STANtiP.S, '000PE� ,,: WIRECTOR
<br />^ Jt r
<br />LINCOLN, NEBRASKA BUREAU OF V�ir�L'$TATISTICS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 12 SEX 3. DATE OF DEATH !Month. Day. Year;
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Harold Peter Speak Male 1 December 5, 1991
<br />4. CITY AND STATE OF BIRTH (N not rn USA, name cwntry)
<br />AGE Las! Blnhday
<br />t Y R
<br />6. DATE OF BIRTH ,Mon M. Day. Year)
<br />50. MOS. DAYS Sc. HOURS' MINS
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNOET.,
<br />15a
<br />(Yrs.i
<br />26C. HOUR OF INJURY
<br />Grand Island, Nebraska
<br />83
<br />April 8, 1908
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH }Y[
<br />NE
<br />261. PLACE OF INJURY - At home, tam, street factory,
<br />office Wilding. ed. ( Specify)
<br />HOSPITAL. Inpatient C ER Ostpabem u DOA
<br />1 507 10 3957
<br />I OTHER ❑ Nursing Home Zj Residence :1 Other ,Speci fy )
<br />8b FACILITY - Name (N nor inson~ gore street and number)
<br />Sc . CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />December 5. 1991
<br />d.
<br />(Speciy Yes or No)
<br />I
<br />VA Medical Center
<br />Grand Island,N braska
<br />Yes
<br />Hall
<br />9a. RESIDENCE - STATE
<br />NTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inclding Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />=9b
<br />Hall
<br />Grand Island
<br />215 N. Sheridan 68801
<br />(specify
<br />Yes
<br />10. RACE - le.g., White. Black, American Indlan,
<br />11. ANCESTRY le.g.,ltakan. Mexican, German, etc.)
<br />12. MARRIED.NEVER MARRIED, t3.
<br />NAME OF SPOUSE (N wile. give maiden name)
<br />etc.) ( specify)
<br />/Specify)
<br />WIDOWED. DIVORCED (Specify)
<br />White
<br />Irish 0q
<br />Married
<br />Opal N. Cooper
<br />tea. USUAL OCCUPATION (Give kind of work done during most
<br />1 ♦b. KIND OF BUSINESS INDUSTRY
<br />1
<br />of working life, even d refired)
<br />Elementary or Secondary (0 -121 1 College 11 -A or 5 -)
<br />Truck Driver �'��
<br />Trucking Industry y10
<br />12th
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />(Dec.) Jerry J. Speak
<br />(Dec.) Anna McIntyre
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />(Yes, no, or unk.)
<br />Yes
<br />(g yes, give war and dates of servdes)
<br />WWI14 /4/42- 10/26/45
<br />Opal N. S eak,221�- Sheridan,Grand Island,NE 68801
<br />20a BURIAL, Cremation,Removal,
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME
<br />20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />B rial
<br />Dec. 9, 1991
<br />Westlawn Memorial Park
<br />Grand Island NE.
<br />MX ER - SIGNATURE B�NSE NO --
<br />22, FUNERAL HOME •NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />d
<br />fel- Butler - Geddes 1123 W. 2nd, Grand Island, NR-68801
<br />WPA t ... � ..... ........� Ic., r c.. vn� r vnc a,�uoc r�r, uric rvn tat. ,u,. n 1.11 Interval between onset and death
<br />It 1a1 _ Cardin -. spiratory Arrest 15 minutes
<br />""� •"• "^ ^" ^ `�`^• °�`^�r -"`�� `rte. i Interval between onset NW 008M
<br />b, Chronic Obstructive Pulmonary Disease 10 years
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and dead)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART
<br />11
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />24 . AUTOPSY
<br />(Specify Yes or No)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />Malnutrition
<br />Yes :1 No 0
<br />NO
<br />(specify Yes or No)
<br />NO
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNOET.,
<br />26b. DATE OF INJURY (Mo..Day. Yr)
<br />26C. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Specify)
<br />26e. INJURY AT WORK
<br />(Specify Yea or No)
<br />261. PLACE OF INJURY - At home, tam, street factory,
<br />office Wilding. ed. ( Specify)
<br />269. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />274L DATE OF DEATH (MO.. Day. Yr.)
<br />28a DATE SIGNED (MO.. Day, Yr.)
<br />28b. TIME OF DEATH
<br />a
<br />December 5. 1991
<br />d.
<br />27b. DATE SIGNED IMO, Day, Yr.)
<br />27c. TIME OF DEATH
<br />28c, PRONOUNCED DEAD (MI Day, Yr.)
<br />28d. PRONOUNCED DEAD (lour)
<br />Dec. 16, 1991
<br />2:35 P
<br />E
<br />27d. To 1M Dal of my knowledge, death occurred at drtte, date and place and due b the
<br />cause(s) stated. r
<br />e and Title � 7
<br />28e. On file basis of examination andlor investigation, in my opinion death occurred at
<br />fire 1wM, date and plus and due b 6N cauae(a1 stated.
<br />to and Tills
<br />20a DID TOBACCO USE CONTRIBUIt TO THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />YES - O ND ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES ro
<br />Khawar M er. M.DO. V; Medical Center, 2201 N. Broadwell, Grand Island,NE 68803
<br />
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