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WHEN THSS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH; ANDJANIA&M SYSTEM, IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL OAUALJ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS_ ?if Kj THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE APR 112002 2 0 0 4 0 9 3 4 0 ASSI3 4 -- LINCOLN, NEBRASKA HEALTH AND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkW AN VITAL STATISTICS C . CERTIFICATE OF DEATH ft ',�� I DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH 'IMonrh Day ✓earl Jerry Lee Sheffield Male March 31, 2002 d. CITY AND STATE OF BIRTH of not kr USA.. name country) 5a. AGE -Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH iMCrnth. Day. Year) Grand Island, Nebraska "(5160 5° Jul 1 1941 Y MOS i DAYS 5c HOURS MIN$ 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 507 -44 -6908 HOSPITAL [N Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b FACILITY - Name IN nonnslitulinn, give street and number) St. Francis Medical Center ❑ DGA ❑ Other rspec ty, _ 8c CITY TOWN OR LOCATION OF DEATH 8tl INSIDE CITY LIMITS Ife COUNTY OF DEATH Grand Island Yes 7 Np ❑ Hall 9a. RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER /InUudm Lp Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 4227 Vermont Ave. 68803 Yesj]N° ❑ 10 RACE - leg. White. Black, American Indian. 11 ANCESTRY leg. Italian. Mexican, German, etcl 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE tll wile. give maiden name) etc) ISM ite (Specifyl English /German ❑ NEVER F1 DIVORCED MARRIED Barbara Baxter 14a USUAL OCCUPATION IGrve kind of work done during KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) of working life, even d rebredl 771lb Cash Register Company Eleme "f`,pr Secondary m -, 2) allege It aorS l Owner 0 erator 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME Charles Sheffield F Margaret Shriner 18 WAS DECEASED EVER IN U.S. ARMED FORCES' 19a INFORMANT - NAME (Yes no or uri III yes. give war and dates of serviced No No I Barbara Sheffield 19b MAILING ADDRESS (STREET OR R.F D. NO.. CITY OR TOWN. STATE. ZIPI 4227 Vermont Ave., Grand Island, NE. 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO 21 a METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME /L27 [Burial ❑Removal April 3, 2002 Grand Island Cemetery a. UNERAL HOME -NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes ❑Cremation ❑Donaron Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ial. to AND Icll Interval between onset and death PART Cc, fv ,t�= -f- DUE TO. OR AS A CONSEQUENCE OF Interval between onset and dearo _ Im _C Q. ..... J 4 f C.. 4 t yi 6..�. G •l� a .. �' -- - - -- - - -- <�' if DUE TO OR AS A CONSEQUENCE OF In1e—I between onset and death la OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE WAS TH ERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY / IN THE PAST 3 MONTHS' EXAMINER OR CORONER' 17 V1 „ T ! ,7 - A rl d lAges 10 541 Yes 11-1 No F Yes �NO Yes No 26a 26b DATE IF AJURY (Mo. Day Yr) 26c HOUR OF INJURY 26d. DEi�RIB_ HOW INJURY OCCURRED A-0—t Undelerminetl M Suficroe Pending 26e INJURY AT WORK 26f PLACE OF INJURY - At home, farm street. factory 126g LOCATION STREET OR R F D NO CITY OR TOWN STATE HomiciCe Investigation ❑❑ Yes No ❑ office budding. etc lso—ii l 27a DATE OF DEATH tMo.. Day. Yr) 26a DATE SIGNED (Mo. Day Yr 1 2111, TIME OF DEATH 'March 31, 2002 - M d U5 27b DATE SIGNED (Mo. Day. Yrr 27c TIME OF DEATH $ r 28c PRONOUNCED DEAD rMo Day. Yrl J2B PRONOUNCED DEAD (Hour( °a E April 2, 2002 9:12 p. M M 270 To the best of my knowledge dealli oc—lAd at the time. date and olace and due to the ` ° ¢m 28e On he basis of examination and or investigation, in my opinion death occurred at causelsl sratetl. L^x' ° = the I— date and place and clue to the cause(sl stated. � ISi nature and Title) 01 `" ;Si nature and Title) ► 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' KNOWN 1-1 1:1 YES UNKNOWN NO 1:1 ❑ YES ❑ NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Pn n Daniel R. Cronk M.D. 908 N. Ho ard, Grand Island, NE. 68803 32a REGISTRAR 321, DATE FILED BV REGISTRAR 1.d Day. Yr.) APR 8 2002 I