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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SYSTEAC IT CEIUMS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTdA t VITAL STATISTI THE LEGAL DEPOSITORY FOR VITAL RECORDS. A , , i DATE OF ISSUANCE Jv 1/27/2004 200404412 AS: LINCOLN, NEBRASKA HEALTH AND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S$_ VITAL STATISTICS nIU10'r=Td1 A 'rII nn T U A •rU. 1 4 00628 1. DECEDENT - NAME FIRST MIDDLE LAST 2 2. SEX 3 3: _ TE OF DEATH /Month. Day. Year) Irene Mary Arthur F Female J January 14, 2004 4. CITY AND STATE OF BIRTH /enof In U.S.A.. name country/ S Sa. AGE -Last Birthday U UNDER 1 YEAR U UNDER 1 DAY 6 6. DATE OF,.BIIRRT�H�,.,/MO A Day. Year) Sb. MOS. i DAYS S Sc.HOURS' MMS. S Spalding, Nebraska ( (Yrs) 68 S September 7, 1935 7. SOCIAL SECURTIY NUMBER O Be. PLACE OF DEATH 508 -38 -0827 HOSPITAL ❑ I Residence m Bb. FACILITY - Name /yam iMMAW, 9i a s"W and number) 405 East Amity ❑ Sc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS F F�CCUNTY O 98. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Mcludrigbip Code) 7 Nebraska Merrick Clarks 405 East A 71YNSIDE C 10. RACE - (e.g., While. Black. American Indian. 1 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 1 12. ® MARRIED ❑ WIt�WED 1 13. NAME OF SPOUSE (d wile. give maiden name) etc.) (Specify) White I ISVeddyl Pol i sh N NEVER DIVORCED J JOL.,,, ifs Arthur 14a. USUAL OCCUPATION /Give kindol wor1r done dlurrig riast 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only hgh" grade completed) of working life, even yrellred) Elementary or Secondary (0 -12) College If -4 or 511 Housewife D 16. FATHER - NAME FIRST MIDDLE LAST 1 MIDDLE MAIDEN SURNAME 117. M Mary Barnark 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 1 19a. INFORMANT -NAME (Yes. no. or unk.{ fit yes. give war and dates of services) J Jahn Arthur no---------- - - - - -- l li 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 405 East Amity, Clarks, Nebraska 68628 20. EMR MER - SIGNAPJRE 8 ICE E NO. 21a METHOD OF DISPOSITION 21b. DATE - 21 C. CEMETERY OR CREMATORY - NAME -// $' ® ® Banal ❑ 22a. FUNERAL HOME - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Wagner Funeral Home ❑ "ante °n ❑ Ddna"' 3826 W. Stolley P Park Road Grand Island NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1702 31st Street, Central City, Nebraska 68826 23, IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR la). (b), AND (c)) I I Interval between onset and death PART I I I (a) Cancer • J A a (b) I Interval between onset and death DUE TO, OR AS A CONSEQUENCE OF: I Ic) OTHER SIGNIFICANT CONDITIONS -Conditions contrtituting to the death but not related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? 11 (Ages 10 -54{ Yes No Vas No Yes No El 26a 26b. DATE OF INJURY (Mo.. Day YrIno . HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED • Accident ❑ undetermined no injury in • ur M no injury • Suicide ❑ Pending 26e. INJURY AT WORK 261. PLACE aim URY t horng, farm, sseel factory 26g. LOCATION STREET OR R.F.D. NO. _ CITY OR TOWN STATE ❑ Homicide Investigation Yes ❑ No no injury SPeaaYJ YO January DATE SIGNED /MO.. Day. Yr.) 28b. TIME OF DEATH 27a. DATE OF DEATH (Mo.. Day. Y January 14, 2004 January 21 2004 7:57 .m. M Y 27b. DATE SIGNED /Mo.. Day. Yr.J 27c. TIME OF DEATH � < r 28c. PRONOUNCED DEAD (Mo.. Day, Yc) 28d. PRONOUNCED DEAD (Fburl } Big M g January 14 2004 9:00 P.M. M B 27d. To the best of my knowledge, death occurred at the time, date and place and due to the O v 289. OnItlIKp i b RYR igCir in ath occurred at cause(s) stated w K NeIpC Re 1b4M1e (Signature and Title ► store and Title) 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 130A HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 7__ O SENT GRANTED? ❑ YES ❑ NO X❑ UNKNOWN ❑ YES ® NO ❑ YES 12 NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type on Pdm 1 Anthony McPhillips, Merrick ount 32b. DATE FILED BY REGISTRAR /Mo., Y. Yr.) 32a. REGISTRAR �. (M -, IAN 2 3 2004