|
*WN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HlJ1f M ;,M�- -
<br />SYSTEM IT CM MS TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECD F9-
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS 49C fl�"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS s
<br />DATE OF ISSUANCE 200405497
<br />4/23/2003 ASSISTANW*T11T#: y == �1EDSEAL
<br />LINCOLN, NEBRASKA HEALTH AND HUAYIAAfSEM
<br />-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES WNA
<br />VITAL STATISTICS n ^ 4 n
<br />CERTIFICATE of nF.ATH �? ` t l: l l , l 1 9
<br />1. DECEDENT -NAME FIRST MIDDLE I LAST
<br />2. SEX
<br />3. GATE OF DEATH /Month. Day. Year/
<br />Paul Jon Currier
<br />Male
<br />Aril 19, 2003
<br />4. CITY AND STATE OF BIRTH Iffnof h U.S.A. name country/
<br />Sa. AGsE --Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />rn
<br />=
<br />D
<br />Detroit, Michigan
<br />(Y'to Sb
<br />J
<br />October 11, 1952
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />C:
<br />rn
<br />v1
<br />t Br anLGH Medical Center East
<br />❑ DOA ❑ OthertSpecdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes ® No ❑
<br />Be. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />env
<br />2
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Doni han
<br />Yes ❑ No
<br />rn
<br />D
<br />13. NAME OF SPOUSE Of wife. give maiden name)
<br />ntWlli`ie
<br />(Specify) American
<br />�•
<br />14a. USUAL OCCUPATION /Give kind of work done during most 1qq
<br />of working life, even if refired)
<br />7C
<br />=�
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -1
<br />5+
<br />Executive Director
<br />Y a e v e r W
<br />Crane Trust
<br />16. FATHER -NAME FIRST MIDDLE LAST t 7
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />James G. Currier
<br />Betty J. Brink
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.)
<br />N(
<br />(if yes. give war and dates of services)
<br />I
<br />Mark Currier
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />1429 Ryan Road, Hastings, Mifta a 49058 -9530
<br />20. EMBA ER - SIGNATURE d LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1
<br />�'- /z
<br />©Banal ❑ Removal
<br />April 23 200
<br />Parkvi ew Cemetery
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel -Butl er- Geddes Funeral H
<br />n;� Cremation ❑ Donation
<br />Hastings Nebraska
<br />w
<br />1123 West 2nd Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE
<br />CAUSE (ENTER ONLY ON CAUSE PER LINE FOR (a6 (b), AND (c)) I Interval between onset and death
<br />PART
<br />(at
<br />,r
<br />DUE TO, OR Af A CONSEQUENCP OF I Interval between onset and death
<br />I
<br />DUE 70, OR AS A CONSEOUEVE OF I Interval between onset and death
<br />(c) � I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - C itfon i ting to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />rr, 11
<br />26a.
<br />26b. DATE OF INJURY (MO.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />2fid. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />3
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE OF,INJURY /At hoq. farm, street. factory
<br />o ee buddl etc. SPec
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />f D
<br />1
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />Can
<br />28b. TIME OF DEATH
<br />L}
<br />M
<br />}
<br />a k r
<br />CID
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day, Yc!
<br />28d. PRONOUNCED DEAD /Fburl
<br />b£
<br />M
<br />M
<br />°
<br />27d. To the bestloffry kn I
<br />causes)
<br />P time, date and dace and due to the 1
<br />28e. On the basis of examination ardor investigation, in my opinion death occurred at
<br />stated.
<br />v
<br />the time, date and pace and due to the cause(s) stated.
<br />(Signature and Tide) ►
<br />lLn
<br />(Signature and Title ) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE EA 30..
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES NO U KNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />C3,1
<br />Lot Thirty-One (31), Amick Acres
<br />East Subdivision,
<br />Hall County, Nebraska.
<br />APR 2 2 2003
<br />*WN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HlJ1f M ;,M�- -
<br />SYSTEM IT CM MS TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECD F9-
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS 49C fl�"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS s
<br />DATE OF ISSUANCE 200405497
<br />4/23/2003 ASSISTANW*T11T#: y == �1EDSEAL
<br />LINCOLN, NEBRASKA HEALTH AND HUAYIAAfSEM
<br />-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES WNA
<br />VITAL STATISTICS n ^ 4 n
<br />CERTIFICATE of nF.ATH �? ` t l: l l , l 1 9
<br />1. DECEDENT -NAME FIRST MIDDLE I LAST
<br />2. SEX
<br />3. GATE OF DEATH /Month. Day. Year/
<br />Paul Jon Currier
<br />Male
<br />Aril 19, 2003
<br />4. CITY AND STATE OF BIRTH Iffnof h U.S.A. name country/
<br />Sa. AGsE --Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month Day. Year/
<br />MOS. l DAYS
<br />Sc.HOURS' MINS.
<br />Detroit, Michigan
<br />(Y'to Sb
<br />J
<br />October 11, 1952
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />381 -58 -4923
<br />HOSPRAL D Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence _
<br />r 8b. FACILITY - Name (It nor institution, give street and numberl
<br />t Br anLGH Medical Center East
<br />❑ DOA ❑ OthertSpecdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes ® No ❑
<br />Lancaster
<br />Be. RESIDENCE -STATE
<br />9b. 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 />Doni han
<br />31 Lillian Lane 68832
<br />Yes ❑ No
<br />10. RAA��C��{E,,,,- (e.g., While. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican. German, etc
<br />12. ❑ MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE Of wife. give maiden name)
<br />ntWlli`ie
<br />(Specify) American
<br />X MA ER DIVORCED
<br />14a. USUAL OCCUPATION /Give kind of work done during most 1qq
<br />of working life, even if refired)
<br />IND OF BUST S$ INDUSTRY,
<br />X` t t `11 hopping
<br />15. EDUCATION (Speciy only highest grade Completed(
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -1
<br />5+
<br />Executive Director
<br />Y a e v e r W
<br />Crane Trust
<br />16. FATHER -NAME FIRST MIDDLE LAST t 7
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />James G. Currier
<br />Betty J. Brink
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.)
<br />N(
<br />(if yes. give war and dates of services)
<br />I
<br />Mark Currier
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />1429 Ryan Road, Hastings, Mifta a 49058 -9530
<br />20. EMBA ER - SIGNATURE d LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1
<br />�'- /z
<br />©Banal ❑ Removal
<br />April 23 200
<br />Parkvi ew Cemetery
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel -Butl er- Geddes Funeral H
<br />n;� Cremation ❑ Donation
<br />Hastings Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West 2nd Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE
<br />CAUSE (ENTER ONLY ON CAUSE PER LINE FOR (a6 (b), AND (c)) I Interval between onset and death
<br />PART
<br />(at
<br />-I
<br />DUE TO, OR Af A CONSEQUENCP OF I Interval between onset and death
<br />I
<br />DUE 70, OR AS A CONSEOUEVE OF I Interval between onset and death
<br />(c) � I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - C itfon i ting to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (MO.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />2fid. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE OF,INJURY /At hoq. farm, street. factory
<br />o ee buddl etc. SPec
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />L}
<br />M
<br />}
<br />a k r
<br />27b. DAT SIGNE (MO.. y. Yr.) (
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day, Yc!
<br />28d. PRONOUNCED DEAD /Fburl
<br />b£
<br />M
<br />M
<br />°
<br />27d. To the bestloffry kn I
<br />causes)
<br />P time, date and dace and due to the 1
<br />28e. On the basis of examination ardor investigation, in my opinion death occurred at
<br />stated.
<br />v
<br />the time, date and pace and due to the cause(s) stated.
<br />(Signature and Tide) ►
<br />(Signature and Title ) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE EA 30..
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES NO U KNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type orPnnt))�)
<br />�1` es S - HcMerr f (5 fh �* CU' nc0 f n N f- R50
<br />32a. REGISTRAR 1
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />APR 2 2 2003
<br />
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