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�a m = D rn Cf) M CA H q s Z _ °rte c� N IN <br />N --i rr1 O 8. <br />n O T n cDii _c -G O O <br />N s <br />0 rn O <br />O O Co <br />(�' 4 vrn M, O D ;10 _C <br />co <br />f V '�Z- <br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEPA IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE . _ KP"- WITH , <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC�� JS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = =L­ T <br />DATE OF ISSUANCE <br />6/11/2003 200404721 <br />ANA & <br />Ass WANr �g7it� <br />1 ltF6�TR� -- <br />LINCOLN, NEBRASKA HEALTH AND H * € . <br />9. <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEiEiEI iR BU!'PORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH - n q n F A F R <br />1. DECEDENT -NAME FIRST MIDDLE UST <br />2. SEX <br />3. DATE OF DEATH /Monts. Day. Year) <br />Elton Emmett Dubbs <br />Male <br />June 1 2003 <br />4. CITY AND STATE OF BIRTH Olrafin U.S.A.. name counhy) <br />Sa AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Monts. Day. Year) <br />Shelton Nebraska <br />(Yra184 Sb.MOS. <br />September 23, 1918 <br />DAYS <br />5c.HOURs' MINS. <br />T SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />e 505 -18 -1625 <br />HOSPITAL: Inpatient OTHER: ® Nursing Home - <br />- - <br />ER OutpatbM Residence <br />8b. FACILITY - Name knot insstaubo ,,give sheer and numbyar.J�,, <br />v' Co. <br />Western Hall Co Good Sam. CI.J,. <br />DOA Other /SpecAvr <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Sd. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />W <br />Yes [X No <br />9a RESIDENCE - .ATE <br />!$1. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Wood River <br />1311 Main, 68883 <br />Yea ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican, German, ski <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE tlt wile. give maiden name) <br />eta _L�cily) <br />(Specdyb _ hemian /Dutch <br />I <br />NEVER DIVORCED <br />Jean Allan <br />14a. USUAL OCCUPATION /Give kind of work dorre during mostt 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of working life, even it retired) <br />Ebmentary or Secondary 10 -12) College 11 -4 or 5-1 <br />16. FATHER -NAME FIRST MIDDLE ST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Dmwtt Dubbs <br />Nora Dean <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes no. or unk.) (if yes. give war and dates of services) <br />19b. INFORMANT . MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) <br />1311 Main River- 681983 <br />20. EMBA SIGN UREB CEN <br />2 O <br />21 a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />! <br />® Btrdal ❑ Removal <br />June 4 2003 <br />Cameron Cemetery <br />22a. FIAOUL HOME -Nvv 1 <br />21 d. CEMETERY OR CREMATORY LOCATION- CITY OR TOWN STATE <br />[I GMMabDn ❑ Donation <br />A fel Funeral Home <br />Wood River NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />411 West 11th Street P.O. Box 1:26 Wood River NE 68883 <br />23. IMMEDIATE CAUSE ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)l I Interval between onset and seam <br />PART {- j- i(EEN�TrER <br />r.`u 4,k s� SI�Vh►� \V�Y I Y� 2_wts <br />I I <br />r DUE T(O, OR� AS A CONSEQUENCE OF I Interval between onset are death <br />VY\ &Y\ ��/1 NAf %%X VAC <br />(b) <br />DUE TO, OR AS A CONSEQUENCE OF: l Interval between onset and death <br />OTHER SIGNIFICANT C 10 NS - Cendtrons contrtellGng to the death but not related PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PA (r' 11A A New (1).. PREGNANCY <br />it 4 J � Ye + `1 UA " `. y <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />j 1 �' ` •v " ,Ages <br />10 -541 Yes No 1711 <br />Yes No Ves NO <br />26a. <br />26b. DATE OF INJURY tMo.. Day. Yr.) <br />26C. HOUR OF INJURY <br />26d DESCRIBE HOW IN,iJRY OCCURRED <br />❑ Accident El Undetermined <br />tiii� AT <br />M <br />Suicide r_1 Pending <br />269. INJURY AT WORK <br />261. 0P Ih Idi AeCEE 7N �Uto V /At , farm, street factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes E] No E] <br />27a. DATE OF DEATH (W.. Day. Yr.) <br />28a. DATE SIGNED tMo.. Day. Yr.) <br />28b. TIME OF DEATH <br />27b. DATE SIGNED tMer. Day. Yr.) <br />27c. TIME OF DEATHC +( <br />28c. PRONOUNCED DEAD tAlo.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Four! <br />27d. To the best of my knowle!(=+cs rod and due to the <br />28e. On the basis of examination and,or investigation, in my opinion death occurred at <br />cause(sl stated. • <br />5 <br />the time, date and place and due to the Causelal stated. <br />(Signature and Title) 1, <br />(Signature and Title) <br />29. DID TOBACCO USE CONTRIBUTE TO TH FATH? 30.a <br />HAS ORGAN OR TI SUE DONATION B�EEyN, CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />YES NO 1:1 UNKNOWN <br />E] YES IJCI NO <br />YES Is NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print) <br />S L Huse° MD <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />JUN 10 2003 <br />u <br />RE: Lot Eight (8) and the North Half (N2) of Lot Seven (7), Block Three (3), Dodd and <br />Marshall's Addition to Wood River, Hall County, Nebraska. <br />