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4009 Mason Ave., Grand Isle
<br />BALMER - SIGNATURE 8 LICENSE NO.
<br />kt,*J� R r "/ /43
<br />UNERAL HOME - NAME
<br />, Nebr
<br />21 a. METHOD 0
<br />FBurial
<br />803
<br />21b. DATE 21 C. CEMETERY OR CREMATORY
<br />❑Removal Apr. 17 20041 Westlawn
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H. Cremation ❑DOnakon
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) Grand Island, Nebraska
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ibl, AND (c)) I Interval between onset and death
<br />I
<br />_I (-I Cardiopulmonary Arrest I 0
<br />DUE TO OR AS A CONSEQUENCE OF Irterval between onset and death.
<br />(b) Unable to take food or fluids orally D ys
<br />DUE TO OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />fcl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />viiALL, srnnszlcs � o
<br />04221
<br />24 AUTOPSY
<br />�i'
<br />CERTIFICATE OF DEATH =
<br />L DECEDENT - NAME FIRST
<br />n >
<br />Clyde
<br />Robert Kin sle Aril 13 2004
<br />4. CITY AND STATE OF BIRTH ltinot m USA.. name country)
<br />c
<br />C: n =
<br />9
<br />Bradshaw, Nebraska
<br />(Yrs.l 5b. MOS. DAYS MINS.
<br />83
<br />Z.
<br />= r )
<br />NUMBER
<br />C) -4
<br />508 -14 -9100
<br />CA
<br />8b. FACILITY -Name /i /not institution, give street and number) ❑ ER Outpatient ❑ Residence
<br />Grand Island Veterans Home
<br />❑ DOA ❑ Other(Speatv)
<br />U) 7C S
<br />z m
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Suicide El Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE QF, INJURY - Al hom9,farm, street. factory
<br />o Ice budding, etc. /Specify
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />Yes ® No ❑
<br />Hall Count
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (lncluding Zip Code / 9e. INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island 4009 Mason Ave. 68803 Yes J No ❑
<br />1/[l'
<br />Italian, Mexican, German, etc/ ® MARRIED WIDOWED 13, NAME OF SPOUSE (if wife. give maiden name)
<br />(Specify)
<br />White En
<br />112,
<br />fish /Irish NEVER DIVORCED Glenna Louise VanHorn
<br />MARRI
<br />14a. USUAL OCCUPATION /Give kindot work done owing most
<br />of working Ale, even it refired)
<br />14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION lSpeciy only highest grade completed/
<br />Farmer /Accountant
<br />Elementary or Secondary (0 -12) ✓ College 11 -4 or 5 -1
<br />Farm.Mana ement
<br />16. FATHER -NAME FIRST MIDDLE
<br />8 Years.
<br />LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harvey A.
<br />Kingsley Mary
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Mor an
<br />19a. INFORMANT - NAME
<br />D
<br />Yes, 0 03-42 to 01 -23 -46
<br />Glenna Kingsley
<br />19b. INFORMANT MAILING ADDRESS ICTRFFT 11.... Nn - - -- -...,,
<br />ca
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AAV M44AN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC.Q Vl FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STALISL MV* ICH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS " --
<br />_
<br />DATE OF ISSUANCE -'
<br />1
<br />ANL Y . Cfl0
<br />4/16/2004 200405574 �_� __P-ER
<br />AA *SISTAIgT-_3_TAT££ REGWRAR
<br />LINCOLN, NEBRASKA HEALTH AAM RUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVE ES �'AZ6 SIMPORT
<br />4009 Mason Ave., Grand Isle
<br />BALMER - SIGNATURE 8 LICENSE NO.
<br />kt,*J� R r "/ /43
<br />UNERAL HOME - NAME
<br />, Nebr
<br />21 a. METHOD 0
<br />FBurial
<br />803
<br />21b. DATE 21 C. CEMETERY OR CREMATORY
<br />❑Removal Apr. 17 20041 Westlawn
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H. Cremation ❑DOnakon
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) Grand Island, Nebraska
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ibl, AND (c)) I Interval between onset and death
<br />I
<br />_I (-I Cardiopulmonary Arrest I 0
<br />DUE TO OR AS A CONSEQUENCE OF Irterval between onset and death.
<br />(b) Unable to take food or fluids orally D ys
<br />DUE TO OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />fcl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />viiALL, srnnszlcs � o
<br />04221
<br />24 AUTOPSY
<br />�i'
<br />CERTIFICATE OF DEATH =
<br />L DECEDENT - NAME FIRST
<br />MIDDLE LAST 3. DATE OF DEATH /Month. Day. Year)
<br />Clyde
<br />Robert Kin sle Aril 13 2004
<br />4. CITY AND STATE OF BIRTH ltinot m USA.. name country)
<br />j2SjEXj
<br />So. AGE - Last Birthday UNDER 1 YEAR DAY 6. DATE OF BIRTH /Month. Day. Year)
<br />Bradshaw, Nebraska
<br />(Yrs.l 5b. MOS. DAYS MINS.
<br />83
<br />7. SOCIAL SECURTIY
<br />Febr 17 1921
<br />NUMBER
<br />Be. PLACE OF DEATH
<br />508 -14 -9100
<br />HOSPITAL ❑ Inpatient OTHER: Nursing Home
<br />8b. FACILITY -Name /i /not institution, give street and number) ❑ ER Outpatient ❑ Residence
<br />Grand Island Veterans Home
<br />❑ DOA ❑ Other(Speatv)
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Suicide El Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE QF, INJURY - Al hom9,farm, street. factory
<br />o Ice budding, etc. /Specify
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />Yes ® No ❑
<br />Hall Count
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (lncluding Zip Code / 9e. INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island 4009 Mason Ave. 68803 Yes J No ❑
<br />10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g..
<br />etc./ (Specify)
<br />Italian, Mexican, German, etc/ ® MARRIED WIDOWED 13, NAME OF SPOUSE (if wife. give maiden name)
<br />(Specify)
<br />White En
<br />112,
<br />fish /Irish NEVER DIVORCED Glenna Louise VanHorn
<br />MARRI
<br />14a. USUAL OCCUPATION /Give kindot work done owing most
<br />of working Ale, even it refired)
<br />14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION lSpeciy only highest grade completed/
<br />Farmer /Accountant
<br />Elementary or Secondary (0 -12) ✓ College 11 -4 or 5 -1
<br />Farm.Mana ement
<br />16. FATHER -NAME FIRST MIDDLE
<br />8 Years.
<br />LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harvey A.
<br />Kingsley Mary
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Mor an
<br />19a. INFORMANT - NAME
<br />(Yes. no, of unk.) (if yes. give war and dates of services)
<br />Yes, 0 03-42 to 01 -23 -46
<br />Glenna Kingsley
<br />19b. INFORMANT MAILING ADDRESS ICTRFFT 11.... Nn - - -- -...,,
<br />4009 Mason Ave., Grand Isle
<br />BALMER - SIGNATURE 8 LICENSE NO.
<br />kt,*J� R r "/ /43
<br />UNERAL HOME - NAME
<br />, Nebr
<br />21 a. METHOD 0
<br />FBurial
<br />803
<br />21b. DATE 21 C. CEMETERY OR CREMATORY
<br />❑Removal Apr. 17 20041 Westlawn
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H. Cremation ❑DOnakon
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) Grand Island, Nebraska
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ibl, AND (c)) I Interval between onset and death
<br />I
<br />_I (-I Cardiopulmonary Arrest I 0
<br />DUE TO OR AS A CONSEQUENCE OF Irterval between onset and death.
<br />(b) Unable to take food or fluids orally D ys
<br />DUE TO OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />fcl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />PART III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />II
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages 10 -54) Yes No
<br />Ves No
<br />Yes No
<br />' 26a
<br />26b. DATE OF INJURY (Mo.. Day. Yr)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN�JRY OCCURRED
<br />F1Accident ❑ Undetermined
<br />M
<br />Suicide El Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE QF, INJURY - Al hom9,farm, street. factory
<br />o Ice budding, etc. /Specify
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />yes No ❑
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (MO.. Day. Yr.) 28b. TIME OF DEATH
<br />�s Aril 13 2004
<br />27b. DATE SIGNED (Mo.. Day. Yr) 27c. TIME OF DEATH
<br />a' April 14, 2004a�}
<br />M
<br />i 28c. PRONOUNCED DEAD tMo.. Day, Yrl 28d. PRONOUNCED DEAD /Hour)
<br />$a 5:35 P. M¢_°
<br />27tl. To the best of my knowled .death occurred at the time,d;rte and lace and due to the
<br />causefsl stated. - R /
<br />E¢o M
<br />v 28e. On the basis of examination antl,or investigation, in my opinion death occurred at
<br />the time, date and place and due to the causeisi stated.
<br />(signature and Title/ ► ^ �� y/ ) j % ��J
<br />(Si nature and Title ) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE D r 30.a HAS O Aid UE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />F1 YES ® NO El UNKNOWN F7 YES ® NO ❑ YES O NO
<br />31. NAME AND ADDRESS OF CFRTIFIFR IPHYSICIAN rrlRnueec
<br />Sheridan T. Anderson, M.D., Gr d Island V Brans Home, Grand Island, NE 68803,
<br />32a. REGISTRAR 32b. DATE FILED BY REGIA
<br />STRAR PR (1 Day.
<br />K Yr2004
<br />Lot Six (6), Sunset 3rd Subdivision to the City of Grand Island, Hall County, Nebraska.
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