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\, CS r o <br />,m rn y z�- <br />+ <br />i•i Z n S t�TT { CD <br />H n p (D N o -1�� o <br />m N N �, ( �'' Tt = - <br />n ' a CD co <br />c 3 rr- n cn <br />o <br />CD <br />0' ° to r <br />Z <br />0 <br />THE NORTHERLY 12 FEET OF LOT 4 AND ALL OF LOT 2, IN BLOCK 24, IN UNIVERSITY PLACE, AN <br />ADDITION TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA <br />WHEN TMS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH. AMD HrJMMN SERVICES <br />SYSTEM IT CERTE£S ThE BELOW TO BE A TRUE COPY OF THE OR/G/NALJ1FWftr4�•ItILE' WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI6�joils <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS �- �s <br />DATE OF ISSUANCE F <br />9/23/2003 200 405 091 r``R <br />LINCOLN, NEBRASKA HEALTHAMDA arPrOwt <br />STATE OF NENLA G DEPARTMENT OF HEALTH AND HUMAN SERVaM ADS SUWORT (C (d0 <br />VITAL STATIiS= <br />CERTIFICATE DF DRAT9 == n Q 1 n cz n G <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SD( <br />3. DATE OF DEATH (Abnth. Day. Year) <br />James Edward Gorman <br />Male <br />Sev 13 2003 <br />4. CITY AND STATE OF BIRTH /pnof it USA nmrnra county/ <br />Sa. AGE -.Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />6. DATE OF BIRTH /M«Wr. Day. Year/ <br />MOS I DAYS <br />5c. HOURS i - IAINS <br />Fairmont, Minnesota <br />IYrs.l 56 <br />78 <br />May 20 1925 <br />7. SOCIAL SECURTIY NUMBER <br />ad. PLACE OF DEATH <br />' 472 -20 -8.592 <br />HOSPITAL Inpatient OTHER: ® Nursing Fbnle <br />❑ ER•Ou"sart ❑ Residence <br />I 8D. FACILITY - Nerve (Nnof insMutiaa give so"aW n rraW _ <br />t Beverly Healthcare Park Place <br />❑ DOA ❑ Other(spe4yl <br />1Ia CRY. TOWN OR LOCATION OF DEATH 8d. <br />INSIDE CITY LIMITS <br />ea cour1TY OF DEATH <br />Grand Island <br />Yea �. ❑ <br />Hall <br />9a RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d STREET AND NUMBER IhchpigLjp coda/ <br />ga. w51DE CRY LIMITS <br />Nebraska <br />Hall <br />Grand.Island 11931 <br />N. Howard 68803 <br />Yea C No ❑ <br />. <br />10. RACE - k g, While. Black. American Mien, <br />11. ANCESTRY (e g- Imearl. Medean, German. et) <br />12. ® MARRIED. ❑ WIDOWED. <br />I 13. NAME OF.SPQUSE (tl wig§ ow maiden name/ <br />- . e1t1(Seecg1 <br />White <br />(Specm - <br />1 Irish French <br />NEVER D . DIVORCED <br />. <br />Bett Stanton <br />(G&*"Wotarrko&WAApmdaf 14b. <br />KIND OF BUSINESSwDUSTRY <br />15. EDUCATION (So" only tigfled grade- nosteA) <br />MlA aVlen Qretiledl . <br />collage «s -I <br />ouse Mara r <br />12 <br />1 2 <br />NAME FIRST MIDDLE LAST ,7. <br />MOTNEi FIRST MIDDLE MAIDEN SURNAME <br />t1ftUSUALOCCUPATION <br />Mark Gorman <br />Marie Dieudonne <br />EASED <br />EVER IN U.S ARMED FORCES?. <br />,ga INFORMANT -NAME <br />wc) <br />Ie Yea"war and tat.. of <br />IWWI107/26/1943 26 1943 03 13 1946 <br />Bett Jean Gorman <br />MAI.NdG ADDRESS (STREET OR R.FD. NO_ CITY OR TOWN. STATE ZIP) ' <br />N. Howard Grand land 'NE 68803 <br />- SIGNATURE 6 LIC WW'NQ <br />/7 <br />21a METHOD OF DISPOSITION <br />211L p 21a <br />CEMETERY OR CREMATORY - NAME <br />a 1092 <br />❑Bahl ❑,;a1 <br />Sep 17, 2003 <br />Central Nebr. Cremation <br />223C FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />pq 0.11i. ❑ Don. <br />Curran Funeral Chapel <br />719 Front St. Gibbon NE <br />22h FUNERAL HOME ADDRESS _ (STREET OR'RF.D: NO- CITY OR TOWN. STATE. ant <br />3005 South Locust Street Grand Island NE 68801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la) (b), AND Ic)) InIerval between ormet and death <br />PART <br />'(e) Respiratory arrest due to mantel. cell lynphoma <br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death <br />1b) <br />DUE TO. OR AS A CONSEQUENCE OF- I Interval between onset are death <br />I <br />(c) <br />I <br />POTHER SIGNIFICANT CONDITIONS - Codliorm c"brbng to the death but not reeled PART40 <br />IF FEMALE WAS THERE A 24. <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />1.,, -, PREGNANCY <br />a Diabetes Type 2 <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />, (Ages <br />10.54) . Yes No M <br />Yea No <br />Yee No <br />28a. <br />M DATE OF INJURY ff*L Day. Yr./ <br />28c. HOUR OF INJURY <br />28d. DESCRIBE HOW INJURY OCCURRED . <br />oAccident Undeds mined <br />I <br />❑ &Kids ❑ Pending - <br />26e. INJURY AT WORK <br />tb ,fame syeal, fecpy <br />28f. 5a= URY A. <br />2Bg, LOCATION 'STREET OR R.F.D. NO. CITY OR TOWN STATE <br />❑ Fbmieide ktveae9aeorr <br />Yaa ❑ No ❑ <br />etc. <br />27a. DATE OF DEATH (Ab.. Day. Yr./ <br />28s. DATE SIGNED (Ma. Day. Yr) <br />286 TIME OF DEATH. <br />Sep 13 2003 <br />All. <br />M <br />276. DATE SIGNED JW Dry. r.) <br />27c. TIME OF DEATH <br />28a PRONOUNCED DEAD. (A4a. Day,. r../ <br />28d. PRONOUNCED DEAD jHoW <br />y <br />k <br />Y � <br />Se 17 2003 C <br />_ <br />Jz� <br />N K O <br />M. <br />F <br />E b <br />�cj33 <br />27CL T at of ggwkdpe, ems, data and doe to Ihs <br />no. On the basis d exammkmeon and/or Investigation. kl epY10n death dCCtlRad at <br />9 I _ <br />v , <br />the lime. d� and p1aCE 8114 due b e14 CMIaB(5) ]MIM. <br />tad <br />and TW <br />and Tek ISionasurst <br />29. OID TOBACCO <br />USE CONTRI DEATH? 3aa <br />HAS ORGAN OR TISSUE DONATION �B�EEN/�p <br />NSIDERED? 130.b <br />WAS CONSENT GRANTED? - <br />-YES .- O ❑ UNKNOWN <br />❑ YES t. <br />r NO <br />YES �N <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (T)pe arPtW ' <br />.William J. Lawton M.D. 729 VF. Custer Av Grand Island NE 68801 <br />32a REGISTRAR - <br />32b. DATE FILED BY REGISTRAR (At, Day Yr./ <br />U11 <br />