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<br />200405479
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<br />WHEN THIS COPY CARRAES THE RAISED SEAL OF THE NEBRASKA HEALTH ANO HUMAN SERVICES
<br />SYSTEM, R CERTIFIES''THE BELOW TO BE A TRUE COPY OF THE ORIG/NA� Ot?d FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL, STAT1ffMV8kQT1g11i.- 1yHlOH 1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />Zcv
<br />1 Z
<br />0547
<br />DATE OF ISSUANCE n� /� `
<br />2 0 0
<br />4/6/2004 a�slsrAAlrt5A2lSR;
<br />LINCOLN, NEBRASKA HEAL TH#NQ HUMoN"
<br />=
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE� ES � 40a- UP ORT (� �%
<br />vrrAL sTATLSTICS E - f V"
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<br />1. DECEDENT -NAME FIRST MIDDLE . LAST,
<br />2.:SEX ',
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Elmer L. Carruth
<br />Male, `
<br />March 25, 2004
<br />4. CITY AND STATE OF BIRTH /d not in USA... name country)
<br />So. AGE - Last Birthday
<br />UNDER 1 _YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />sb: Mos. I DAYS
<br />sc. Houas Mtr4s.
<br />Scotia, Nebraska
<br />r "'1 80
<br />May 11, 1923
<br />7. SOCIAL SECCURTIY NUMBER --
<br />8a. -PLACE OF DEATH
<br />508-18 -6062 -
<br />HOSPITAL: ® Inpatient OTHER: Nursing Home.
<br />4J Suicide Pending -
<br />ER Outpatient ,. Residence
<br />8b. FACILITY -Name tdnd ins'"m, give a~ and number)
<br />St. Francis Medical Center
<br />0 DOA ❑ Other fspevAa
<br />Bc. CITY. TOWN OR LOCATION OF DEATH -
<br />Bd. INSIDE CITY LIMITS
<br />COUNTY OF DEATH ' -
<br />Grand Island ,
<br />-Yes ❑
<br />[".
<br />Hall
<br />,
<br />No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY"
<br />9c. CITY.rTOWN OR LOCATION
<br />94. STREET AND NUMBER !Including Zip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />4239 W Capital Ave., 68803
<br />Yea Z No
<br />10. RACE • fe.p., White. Black. American Indian
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, eol ..
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE fit wde. give maiden name)
<br />W IIIIBN)
<br />Afll°Mcan
<br />NEVER DIVORCED
<br />Rosie (NMI) Fotinos
<br />14a. USUAL OCCUPATION lGive kind of wool i*fte durblg mast ._
<br />14b. KIND. OF BUSINESS INDUSTRY. ... .. :._
<br />is. EDUCATION
<br />(Specify only highest grade completed)
<br />Eb .or Secondary 10 -12) College 11 -4 or 5.1
<br />'��"
<br />wok Ule. e n tired!
<br />Gp1ons u air
<br />Buildings
<br />16. FATHER -NAME - FIRST - MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Lloyd (NMI) Carruth
<br />Opal (NMI) Clement
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?.. -.
<br />1go. INFORMANT - NAME
<br />lY es °` ° °") Nvorlaa`�ar o1serv1i0`� 01/20/1946
<br />Rosie Carruth
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., GITY OR TOWN. STATE. ZIP)
<br />4239 W Capital Ave, Grand Island, Nebraska 68803"
<br />ALMER -SIGNATURE 6 ICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />211b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />iEM
<br />1037
<br />Burial Removal
<br />❑
<br />121C.
<br />03/29/2004
<br />West Lawn Memorial Park
<br />FUNERAL HOME, NAM - -
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />❑ cremation ❑ Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS , ISTREET OR R.F.D. NO. CITY OR TOWN, STATE, ZIP( •. -
<br />3213 W North Front St Grand Island, NE, 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Is). Ibl. AND (c)) - I Interval between onset and death
<br />PAR
<br />fen t
<br />interval between oMal and death
<br />DUE TO, OR AS A ONSEGUENCE OF cy
<br />[ YL c- !'C= ✓1iZ Cy,
<br />(o t�i ,-YG
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset a
<br />icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contribuWlg to the death but not related -PART
<br />PART .. ... - PREGNANCY
<br />III IF FEMALE WAS THERE A
<br />IN THE PAST 3 MONTHS? -
<br />P$
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />II _ ,.
<br />`'� (A'
<br />..
<br />(Ages 10 -541 Yes No
<br />Yes No
<br />Yea No
<br />26a;; v I
<br />26b. DATE OF INJURY fW Day. Yr.)
<br />26c:, HOUR OF INJURY
<br />" 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />_
<br />M
<br />4J Suicide Pending -
<br />26e. INJURYAT WORK
<br />okA E Al IN INJURY ( wr' arm. street. factory
<br />41.x.
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes 1:1 No E]
<br />1261.
<br />27.a. DATE OF DEATH' (Ma. Day. Yt)
<br />28a. DATE SIGNED Wa. Day. Yr.)
<br />28b. TIME OF DEATH
<br />3
<br />M
<br />DATE SIGNED (Mo. Day, Yr.j - -
<br />27X, TIME QF DDEEATH
<br />28c, PRONOUNCED DEAD (Ma . Day. Yr.)
<br />2Bd. PRONOUNCED DEAD tHourl
<br />-27
<br />.y�' I,.
<br />J
<br />=
<br />a
<br />TO the best d my knowledge, a (occurred at the time. date and place and due to the
<br />daweisl stated... ' ,
<br />289. On me basis d examination and,or investigation, in my opinion death occurred at
<br />the time, date and place and due to the causelsl sided.,
<br />� , `l
<br />G� y Y C
<br />ISi nature and Tfnel ►{ rl • -L .1 , P-" "!""C"' ✓
<br />IS' nature and Tillel No
<br />DID TOBACCO USE CONTRIBUTE TO THE DEA ? - �3fAd
<br />HAS ORGAN OR TISSUE DONATION BEEN C SIDERED�
<br />. WAS CONSENT GRANTED?
<br />YES NO 121UNKNOWN
<br />YES NO
<br />YES El NO
<br />. I AA.ME 4N ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI ljv°e araw)
<br />32a. - REGISTRAR
<br />% t - _
<br />32b:, DATE FILED BY REGISTRAR (Ma. Day. Yi)
<br />APR - 5 2004
<br />I y
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