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WHEN THIS COPY CARRE S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE -WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC SECTION, WW(CH9 THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200405724 V /�,/"V,(J�' DEC Q O 8001 ANEEY 3 COOPER: V 2 L ASSISTANT STATE REGISTRAIf. LINCOLN, NEBRASKA HEALTHAND �'VICFSSYSTEU STATE OF NEBRASKA- DEPARTMENT OF HEALTH � _ S _ 0 9317 CFRT1F1CATF OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATEOF 9&,nf %Monts Day. Y"11 Carol'ean Anne Palu Female Aug 20 2001 _ 4. CRY AND STATE OF BIRTH (d note U.S.A. rune couroyl a Burial ❑Removal Sa. AGE - Lan Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH IMMA Day. Year) Curran Funeral Chapel ❑Dfe11°°" ❑odnatk>n rn' 22b FUNERAL HOME ADDRESS (STREET OR R.F.O. NO CITY OR TOWN. STATE. ZIPi 1AO$ DAYS 51- HOURS' MINIS Hanover, Kansas (al C 1 N p M 68 , DUE TO. OR AS A CONSEQUENCE OF Interval between onset and ceath Oct 11 1932 7. SOCIAL SECURTIY NUMBER MI IF FEMALE WAS THERE A ea. PLACE OF DEATH 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? HOSPITAL: ❑ mpalield OTHER: ❑ Nursing Home . 506-42-4593 ❑ ER Ou"bent Residence 8b. FACILITY - Name Innol a Okfta 9^a sareet and member/ Yee L No 26a. ❑ ODA ❑ Other(Spe" "' 3418 Tri Street 26d. DESCRIBE HOW INJURY OCCURRED . ❑ Accident ❑ Underormined Bc. CRY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes X No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY ❑ Hormclde Irwesagtlaon 9c. CITY, TOWN OR LOCATION STREET AND NUMBER (ktdkA7klg Zp Cade) 9d INSIDE CITY LIMITS NE Hall M. DATE SIGNED (At... Day. Yrl Grand Island 19d 3418 Tri Street 68801 Yea ❑ No ❑ - 10. RACE - le.g., White. Black. American Indan. 11. ANCESTRY (e.g.. Malian. Mexican. German. elcl 12. ❑ MARRIED ® WIDOWED 13. NAME OF SPOUSE (e wile give maiden name) etc.l(SoecM) White (Sp -tyl German /French NEVER DIVORCED 1 Elvin E. Palu deceased 14a. USUAL OCCUPATION /Give rind of work done dwM most 1 1 /t. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only NgIr" grade completed) of _king bk evendreared! 28a. On the basis of examination andror invesagaom, n my agnion dealt. occurred aI cause(sI nerod. J ` ` ^ `. ,-- - y` v a Elemerlw Secondary 10 -12) College 13 015.1 �Registered Nurse ant Tale ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ilia 11 _ 16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Henry Raymond Hunt 1 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) ITMe cv Prinp Karoline Hennetta Bollman _ 18. WAS DECEASED EVER IN U.S. ARMED FORCES? _ 32b. DATE FILED BY REGISTRAR (Mo. Day. 10.) 19a INFORMANT - NAME - (Yes. no. or unk.) (M yea. give war A. Gros of servlceel I Sue Martens 4d99 Tri Rtraat Mvant9 Tal anei NF. ARRM LMER - SIGNATURE d LICi;NsE NO 21a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME . /, j : 092 Zkl a Burial ❑Removal 23 2001 Aug Grand Island City _ a. PUNLRACHOME - IQAIIE 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Curran Funeral Chapel ❑Dfe11°°" ❑odnatk>n 3168 W. Stolley Park Rd. Grand Island NE 22b FUNERAL HOME ADDRESS (STREET OR R.F.O. NO CITY OR TOWN. STATE. ZIPi 3005 South Locust Street Grand Island NE 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 1a). Ib). AND (c)) Interval between onset and oealr. PART �y� (al C 1 N p M DUE TO, OR AS A CONSEOUENCE OF. Interval between onset and ceatn (b) DUE TO. OR AS A CONSEQUENCE OF Interval between onset and ceath (cl OTHER SIGNIFICANT CONDITIONS - Conditions contributing 10 the deam but not related PART MI IF FEMALE WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' V , (Agee 10-54) - Yea No Yea 0 No Yee L No 26a. 26b. DATE OF INJURY (Ab.. Day. Yr/ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED . ❑ Accident ❑ Underormined 1 M ❑ Suicide ❑ Pending 260. INJURY AT WORK 26L PLAe E °F INJURY %At ho g. farm. sMeeL lathy dffii buYd 26g. LOCATION STREET OR ELF O. NO. CITY OR TOWN STATE ❑ Hormclde Irwesagtlaon Yea ❑ No ❑ SPecN/ 27a. DATE OF DE/Ay (MOB. Daayy.' Vr.J(/�l M. DATE SIGNED (At... Day. Yrl 26b. TIME OF DEATH /THH I i a dRl 27b. DATE SIGNED Into.. Day. Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMo. Day. Y.) 28d, PRONOUNCED DEAD (Hour) 1 ,°., �.. Y 27d. To d1g Qgffiy_f my k . oeaet red at cite and pace anrf to V; 28a. On the basis of examination andror invesagaom, n my agnion dealt. occurred aI cause(sI nerod. J ` ` ^ `. ,-- - y` v a the lime, dim WZ5 ace and due to the cause(s) stated. and rilk ant Tale ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ilia HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3D.b WAS CONSENT GRANTED? ❑ YES ❑ NO 7 UNKNOWN ❑ YES NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) ITMe cv Prinp John J. Cannella 729 Nj CusterpAW. Grand Island NE 68801 32a. REGISTRAR Atd�l 6�Tt_%` _ 32b. DATE FILED BY REGISTRAR (Mo. Day. 10.) - III