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<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEAL1ft IJilii5avMCn
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISDft-
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />2/11/2004 200406343 LEY & b
<br />ISTAW50 i REGA'T6AR .
<br />LINCOLN, NEBRASKA HEALTH AW#K*aN SERVICES SYSTEM
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<br />MIDDLE LAST 2 SEX = _ - ~ OF DEATH (AfonM. Day. VNr)
<br />James
<br />Richard Hall Male Jan 8 2004
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<br />Sa AGE -.Last &rdldey UNDER t YEAR UNDER t DAV 6. DATE OF BIRTH /Abner. Oay. Year/
<br />St. Paul, Nebraska.
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<br />7. SOCIAL SECURTIY NUM82R
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<br />as. PLACE OF DEATH
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<br />21& DE SCRIBE HOW INJURY OCCURRED
<br />HOSPITAL• El Inpatient OTHER: ❑ Nursing Home
<br />❑ ER'Ot palm! FA Residence
<br />N. FACILITY - Name trnor irwetu0'on, give abeet andnumbarl
<br />1618 N. Kimball
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<br />❑ DOA ❑ Aber (Speddyr
<br />111 CITY. TOWN DR LOCATION OF DEATH
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<br />Be. COUNTY OF DEATH
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<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION 91 STREET AND NUMBER (1=A PV ZIP Code) 9e. INSIDE CITY LIMIT$
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<br />Grand Island 11618f l N. Kimball 68801 Yea ® No ❑
<br />10. RACE - (ag, White. Black. American kldian. 11. ANCESTRY le.g.. 181fen, Mexican, Gemten, etc) 12 ® MARRIED, ❑ WIDOWED 13. NAME OF.SPOUSE (d wife. g/wa maiden name)
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<br />M Brenda Tull
<br />148. USUAL OCCUPATION /Gina kinder' eat( dare dt,*V most
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<br />14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify ony hgheet grade canpteald)
<br />Owner/Manager
<br />Elerrlentary2 SearMa1Y (0 -12) College 114 or 5.1
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<br />It FATHER -NAME FIRST MIDDLE
<br />LAST MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clifford
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<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEAL1ft IJilii5avMCn
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<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISDft-
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />2/11/2004 200406343 LEY & b
<br />ISTAW50 i REGA'T6AR .
<br />LINCOLN, NEBRASKA HEALTH AW#K*aN SERVICES SYSTEM
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<br />7!. SKiNATUAE &.LIC, N0, 21a METHOD OF OSpOS1T10N 21 b.. DATE
<br />-y, - 21 c. CEMETERY OR CREMATORY - NAME
<br />X❑ Bt.tel ❑ �, Jan 12, 2004 Westlawn Memorial Park
<br />22L FUNERAL HOME - NAM NAMV 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Curran Funeral Chapel ❑ `�""'�°" ❑ °anato 3826 W. Stoiiev Park RA T-1--A VTIV
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<br />VI1i1L SPATNTIC$ 4 00201
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<br />CERTIFICATE OF DEATH =�
<br />1. DECfr MT - NAME FIRST
<br />MIDDLE LAST 2 SEX = _ - ~ OF DEATH (AfonM. Day. VNr)
<br />James
<br />Richard Hall Male Jan 8 2004
<br />4. CITY AND STATE OF BIRTH /Mwwfie USA.. ralrrte doui4ry)
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<br />Sa AGE -.Last &rdldey UNDER t YEAR UNDER t DAV 6. DATE OF BIRTH /Abner. Oay. Year/
<br />St. Paul, Nebraska.
<br />(Yre.l Sb. MOS. DAYS 50. HOURS; MINS. - -
<br />_ 58 I - - Jan 27 1945
<br />7. SOCIAL SECURTIY NUM82R
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<br />as. PLACE OF DEATH
<br />508 -52 -.070
<br />21& DE SCRIBE HOW INJURY OCCURRED
<br />HOSPITAL• El Inpatient OTHER: ❑ Nursing Home
<br />❑ ER'Ot palm! FA Residence
<br />N. FACILITY - Name trnor irwetu0'on, give abeet andnumbarl
<br />1618 N. Kimball
<br />❑ DOA ❑ Aber (Speddyr
<br />111 CITY. TOWN DR LOCATION OF DEATH
<br />8d. INSIDE CITY UMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
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<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION 91 STREET AND NUMBER (1=A PV ZIP Code) 9e. INSIDE CITY LIMIT$
<br />Nebraska Hall
<br />Grand Island 11618f l N. Kimball 68801 Yea ® No ❑
<br />10. RACE - (ag, White. Black. American kldian. 11. ANCESTRY le.g.. 181fen, Mexican, Gemten, etc) 12 ® MARRIED, ❑ WIDOWED 13. NAME OF.SPOUSE (d wife. g/wa maiden name)
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<br />Swedish NEVER DIVORCED
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<br />148. USUAL OCCUPATION /Gina kinder' eat( dare dt,*V most
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<br />14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify ony hgheet grade canpteald)
<br />Owner/Manager
<br />Elerrlentary2 SearMa1Y (0 -12) College 114 or 5.1
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<br />It FATHER -NAME FIRST MIDDLE
<br />LAST MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clifford
<br />117,
<br />Hall Olenda Hed fin
<br />IS WAS OWEASED EVER IN U.S. ARMED FORCES? .
<br />19a. INFORMANT -NAME
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<br />1618 N. Kimball Grand Island NE 68801
<br />7!. SKiNATUAE &.LIC, N0, 21a METHOD OF OSpOS1T10N 21 b.. DATE
<br />-y, - 21 c. CEMETERY OR CREMATORY - NAME
<br />X❑ Bt.tel ❑ �, Jan 12, 2004 Westlawn Memorial Park
<br />22L FUNERAL HOME - NAM NAMV 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Curran Funeral Chapel ❑ `�""'�°" ❑ °anato 3826 W. Stoiiev Park RA T-1--A VTIV
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<br />21b DATE OF Kkof ma. Dy. N.)
<br />23c. HOUR OF INJURY
<br />21& DE SCRIBE HOW INJURY OCCURRED
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<br />27a DATE OF DEATH (Ma. Day. Yr.)
<br />. DATE SIGNED (Ala. Day. Yr.) TIME OF DEATH
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<br />27b. GATE SIGNED (Ala Day. Yr.) 27c. TIME OF DEATH
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<br />. and Tate and TIME .
<br />USE CO HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? TED
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<br />Oq TOBACCO
<br />❑ YES 0-No UNKNOWN ❑ YES 13 NO YES NO
<br />AND ADDRESS OF CERTIFIER IPHYSK:IAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Typed Prim/
<br />SGT. BUD EDWARDS, GRAND ISLAND POLICE DEPARTMENT, 131 S. LOCUST ST, GRAND ISLAND, N
<br />32a. REGISTRAR -
<br />326. DATE FILED BYR7pEGISTRAR (A/a, D Yr./
<br />14 200
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<br />JAN
<br />LOT ONE (1) IN BLOCK NINZTY (90), IN WHELrLER AND ITT1! 110URTX
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