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n s off; CD <br />n 2 -� �� rn� m fD <br />z - t -T7 -+ o Q. <br />n � <br />m A <br />n iC <br />`'D trn 7 t4 r- >_ O <br />Q F-' CD CD <br />i` O D O CD <br />CO O O <br />H <br />C? Q <br />n e': <br />(7) <br />N <br />d % <br />• <br />H <br />In 00 <br />r <br />0 <br />V <br />r �• <br />rN <br />v <br />Ch <br />H <br />z <br />by rn <br />cn Ir. <br />C <br />cd <br />w <br />H <br />0 <br />z <br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEA4 IT CERTFFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD- ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS �. <br />DATE OF ISSUANCE <br />2/26/2004 200408908 AsMI_ -, <br />LINCOLN, NEBRASKA HEALTH AII� HLAti1AVICE.4 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERFAIZf�3IjtI <br />VITAL STATISTICS -�w IJ � /� F C0 / �% <br />0 <br />CERTIFICATE OF DEATH s: "` <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH tMatth. Day. Year) <br />Craig Allen Cummings <br />Male <br />February 10, 2004 <br />4. CITY AND STATE OF BIRTH /Moot in U.S.A.. name Cdtmtty/ <br />5a. AGE -Last 8lrthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Mantle Day. Year) <br />DAYS <br />5c. HOURS MINS. <br />Los Angeles, California <br />(Yrs.l 61 5b.MOS.1 <br />J une 30, 1942 <br />7. SOCIAL SECURTIY NUMBER <br />Be- PLACE OF DEATH <br />HOSPITAL: ❑ In,,- OTHER: E Nursing Home <br />506 -46 -0515 <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name /d not inatiNtion, give street and number) <br />Veterans Affairs Medical Center <br />❑ DDA ❑ Other (spec4i <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />ea. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Grand Island - - - <br />-a El <br />Ill _ <br />9a. RESIDENCE -STATE <br />gb. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (IncludirlgZip Code) <br />9e, INSIDE CITY LIMITS <br />Nebraska <br />I Hall <br />Grand Island <br />1111 South Lincoln, 6880 <br />Yea ® No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, elcl <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE ht wife. give maiden name) <br />etc.) (specify) White <br />($p9ody) American <br />NEVER DIVORCED <br />Petty Amareau - <br />14a. USUAL OCCUPATION /Give kind of work date during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elementai i Secondary (0 -12) 11 -4 or 5-I <br />of working /tle. won Mredradl - <br />Security Guard <br />Ford New Holland <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Arthur, Cummings <br />Betty Ann Moore <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. <br />INFORMANT - NAME <br />(Yes. no. or unk.) (t yes. give war and dates d services) <br />Yes 8-16-1960 to 11 -30 -1982 1 <br />Crystal s t a 1 Cummin s - <br />y g <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP) <br />1111 S. Lincoln, Grand Island, NE. 68801 <br />,TO. EMBA ER - SIGNATURE 8 LICENSE NO. 3 <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />/ <br />®atrial ❑Removal <br />Feb. 13, 2004 <br />Grand Island Cemetery <br />. FUNERAL E -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel - Butler- Geddes <br />❑Cremation ❑Dona°°^ <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, NE. 68801 <br />MEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Tai. (b). AND (c)I I Interval between onset and death <br />ti Lun C ancer lYear <br />rPART <br />UE TO, OR AS A CONSEQUENCE OF Interval between onset and death <br />Few Months <br />Liver Metastasis <br />UE TO, OR AS A CONSEOUENCE OF: Interval between onset and death <br />Few Months <br />(c) Anorexia <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />II COPD (Ages, <br />10 -541 Yea No <br />Yes No <br />Yea No IN <br />26a. <br />26b. DATE OF INJURY (MO.. Day. Yr) <br />26c. HOUR OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />Accident 7 Undetermined <br />M <br />126d <br />Suicide ❑ Pending <br />269, INJURY AT WORK <br />261. o home <br />btx'IdkN B1AY �A1 _- , farm. sheet. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />clt a �fil <br />27a. DATE OF DEATH (Mo.. Day Yr.) <br />28a DATE SIGNED /Ab.. Day. Yr.) <br />28b. TIME OF DEATH <br />FebmigU 10 2004 <br />=' <br />b- c� � <br />M <br />27b. DATE SIGNED /MO.. Day. Yr.) <br />27c. TIME OF DEATH <br />a g y <br />29c. PRONOUNCED DEAD (Mo.. Day, Al <br />28d. PRONOUNCED DEAD (Hour) <br />d � <br />10 2004 <br />2.30 am M <br />M <br />g <br />,°- <br />2 W � <br />~ ° a <br />27d. To the best of my knowledge. each occurred al the tiry�s, date and place and due to the <br />289. On the basis of examination and,or investigation, in my opinion death occurred at <br />01e <br />causelsl sated / �, <br />the time, date and place and due to cause(s) stated. <br />fJ� <br />IS nature and Tide) �`�� ' <br />(Si nature and Title) ► <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />3Qa HAS ORGAN 0 TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES ❑ NO ® UNKNOWN <br />YES ❑ NO <br />❑ YES ® NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI IType or Print) <br />Neena Biswas MD VAMC Grand Island; 20 . Broadwell, Grand Island, NE 68803 <br />32a. REGISTRAR <br />I <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr-) <br />FEB 1 8 2004 <br />1 V <br />