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200409630 <br />WHEN THIS COPY CMWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEF4 IT CERT>FES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REG AI:FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM__ C<11S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS y E' <br />DATE OF ISSUANCE O <br />AAILEY$ COSiPPER <br />9/12/2003 AssirANrsf3il�Fo <br />LINCOLN, NEBRASKA HEALTHAWAWMN3ERVICES } <br />STATE OF MMASKAA DEPARTNU f OF HEALTH AND HU41AN SF V c T` <br />VITAL STATICS a - Q 10172 <br />r�FUTrFrr -sue nF nRerrr j_ <br />1. OECFAENT - NAME FIRST <br />MIDDLE LAST <br />2 S IX <br />9. DATE OF DEATH . f fonm. Day. Year1 <br />Valeria <br />17 <br />Carol Warns <br />Female <br />Sep 2 2003 <br />4. CRY AND STATE OF BIRTH (A'naf r USA- name caw"I <br />286. DATE OF INJURY (Ala- Dry. Yr.) <br />Sa. AGE -.Lag RIrnWsY <br />UNOFA 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH f m ft Dey. Year/ <br />5b. MOS DAYS <br />5C. HOURS'- - MINS. <br />St=be Pending - <br />M <br />fYM1 <br />LOCH -11014 'STREET OR F FJ1 NO. ' CRY OR 701M4 STATE <br />= <br />Yee ❑ Nd ❑ <br />C=' <br />c3 -4 <br />,n <br />7. SOCIAL SECURTIY NUMBER <br />28a. DATE SIGNED (MO- Day Y rI <br />m y <br />`.! <br />C=�-( <br />8b. FACILITY - Name /pna/inMll6oni. gne easel <br />Z <br />a� <br />❑ DOA ❑ Dow( I <br />` <br />cam': <br />rn <br />-a M <br />8e CITY. TOWN OR LOCATION OF DEATH <br />28c. PRONOUNCED DEAD. lA1a Day. Yr.) <br />8d INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® N1O ❑ <br />Hall <br />9a. RFSIDFNCE -STATE <br />N <br />1:10 am <br />M <br />-t. CITY. TOWN OR LOCATION <br />8d STREET AND NUMBER (ntekra15Z/F CWef <br />9e. 8'ISIDE CITY LIMITS <br />W <br />p +t <br />['1 <br />CA <br />1309 W 7th St. 68801 <br />Yee No ❑ <br />10. RACE - (ag, WNIe Black. American Mdlarl. <br />11. ANCESTRY(eg.. taterh. MexKW. 00111an, toe) <br />O <br />-*t <br />. adt.) (SWIM <br />White <br />(SDecrm <br />I Irish <br />- <br />German <br />NEVER DIVORCED <br />I <br />113, <br />. <br />Robert Warnes <br />14. USUAL OCCUPATION /Give kind of wwk dare db'+'(g maef <br />CONSIDERED? <br />14b. KIND OF BUSINESS INDUSTRY - <br />15. EDUCATION (Sp" orgy N0*Agrede camPleled) <br />E�y or SWWKWY (0-12) Collage 11-4 or 5.1 <br />of waking Aft even i/refto <br />NO <br />Bookkeeper <br />Michelle J Oldham, Dep Hall County Attorney, 231 S Locust, Grand <br />XZ& REGISTRAR <br />12 0. <br />18. FATHER - NAME FIRST MIDDLE <br />LAST' <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Clyde <br />m <br />3 <br />r <br />19a INFORMANT - NAME <br />(Ye& ra. or utt) in Yes. 9r4e war and dada of services) <br />5 <br />r b <br />1716. INFORMANT' MAI ING ADDRESS (STREET OR R.F.D. NO, CRY OR TOWN. STATE ZIP) <br />309 W 7th St. Grand Island NE.68801 <br />9 EMBALMER - SIGNATURE &LICENSE. NO. <br />21a. METHOD OF MMSRION <br />21b.. DATE 21a. <br />CEMETERY OR CREMATORY - NAME <br />�, <br />cn <br />Sep 3, 2003 <br />Central Nebr. Cremation <br />22'a FUNERAL HOME -NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOVM STATE <br />Curran Funeral Chapel <br />� <br />x <br />cn <br />cn <br />200409630 <br />WHEN THIS COPY CMWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEF4 IT CERT>FES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REG AI:FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM__ C<11S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS y E' <br />DATE OF ISSUANCE O <br />AAILEY$ COSiPPER <br />9/12/2003 AssirANrsf3il�Fo <br />LINCOLN, NEBRASKA HEALTHAWAWMN3ERVICES } <br />STATE OF MMASKAA DEPARTNU f OF HEALTH AND HU41AN SF V c T` <br />VITAL STATICS a - Q 10172 <br />r�FUTrFrr -sue nF nRerrr j_ <br />1. OECFAENT - NAME FIRST <br />MIDDLE LAST <br />2 S IX <br />9. DATE OF DEATH . f fonm. Day. Year1 <br />Valeria <br />17 <br />Carol Warns <br />Female <br />Sep 2 2003 <br />4. CRY AND STATE OF BIRTH (A'naf r USA- name caw"I <br />286. DATE OF INJURY (Ala- Dry. Yr.) <br />Sa. AGE -.Lag RIrnWsY <br />UNOFA 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH f m ft Dey. Year/ <br />5b. MOS DAYS <br />5C. HOURS'- - MINS. <br />St=be Pending - <br />2Be. INJURY AT WW <br />fYM1 <br />LOCH -11014 'STREET OR F FJ1 NO. ' CRY OR 701M4 STATE <br />Grand Island, Nebraska <br />Yee ❑ Nd ❑ <br />61 <br />I <br />Dec 8 1941 <br />7. SOCIAL SECURTIY NUMBER <br />28a. DATE SIGNED (MO- Day Y rI <br />8a. PLACE OF DEATH <br />HOSPITAL InPadag OTHER: ❑' Nurairg Home <br />508 -48 -2233 <br />❑ ER °Ou"WrR ® Residence <br />8b. FACILITY - Name /pna/inMll6oni. gne easel <br />8rldraarber( <br />a� <br />❑ DOA ❑ Dow( I <br />309 W 7th. St. <br />27b. DATE SIGNED IMd- Day. Yr) <br />8e CITY. TOWN OR LOCATION OF DEATH <br />28c. PRONOUNCED DEAD. lA1a Day. Yr.) <br />8d INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® N1O ❑ <br />Hall <br />9a. RFSIDFNCE -STATE <br />9b. COUNTY <br />1:10 am <br />M <br />-t. CITY. TOWN OR LOCATION <br />8d STREET AND NUMBER (ntekra15Z/F CWef <br />9e. 8'ISIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand .Island <br />1309 W 7th St. 68801 <br />Yee No ❑ <br />10. RACE - (ag, WNIe Black. American Mdlarl. <br />11. ANCESTRY(eg.. taterh. MexKW. 00111an, toe) <br />12 ® MARRIED. ii WIDOWED. <br />u <br />NAME OF.SPOUSE /Nwdsg- maiden -) <br />. adt.) (SWIM <br />White <br />(SDecrm <br />I Irish <br />- <br />German <br />NEVER DIVORCED <br />I <br />113, <br />. <br />Robert Warnes <br />14. USUAL OCCUPATION /Give kind of wwk dare db'+'(g maef <br />CONSIDERED? <br />14b. KIND OF BUSINESS INDUSTRY - <br />15. EDUCATION (Sp" orgy N0*Agrede camPleled) <br />E�y or SWWKWY (0-12) Collage 11-4 or 5.1 <br />of waking Aft even i/refto <br />NO <br />Bookkeeper <br />Michelle J Oldham, Dep Hall County Attorney, 231 S Locust, Grand <br />XZ& REGISTRAR <br />12 0. <br />18. FATHER - NAME FIRST MIDDLE <br />LAST' <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Clyde <br />Bullis <br />Leona Weiss <br />16 WAS DECEASED EVER IN U.S. ARMED FORCES? . <br />19a INFORMANT - NAME <br />(Ye& ra. or utt) in Yes. 9r4e war and dada of services) <br />No <br />Robert A. Warnes <br />1716. INFORMANT' MAI ING ADDRESS (STREET OR R.F.D. NO, CRY OR TOWN. STATE ZIP) <br />309 W 7th St. Grand Island NE.68801 <br />9 EMBALMER - SIGNATURE &LICENSE. NO. <br />21a. METHOD OF MMSRION <br />21b.. DATE 21a. <br />CEMETERY OR CREMATORY - NAME <br />Not Embalmed <br />❑BUrig ❑R.moval <br />Sep 3, 2003 <br />Central Nebr. Cremation <br />22'a FUNERAL HOME -NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOVM STATE <br />Curran Funeral Chapel <br />® Cama"dah ❑ Danab- <br />719 Front St. Gibbon NE <br />3005 South Locust Street Grand Island NE 68801 <br />21 IMMEMTE CAUSE CENTER ONLY ONE CAUSE PER LINE FOR (a) (bL AND (e)) InWval beh can onset and death <br />PM,I Natural causes unknown <br />DUE TO, OR AS A CON.SEOUENCE OF: asarval between aural and death <br />ro) <br />A <br />1 bwervai oeaieert armet and asem <br />I <br />l <br />3 <br />O� <br />fV <br />O <br />O <br />S � <br />O n <br />C.0 a <br />rnC0 <br />o Z <br />7 <br />(d) <br />OTHER SIGNIFICANT CONDITIONS - Candsions conlnbadng to the deem but nd mhOd PART <br />PART PREGNANCY <br />III IF FEMALE WAS THERE A 1 <br />IN THE PAST 3 MONTHS? <br />24. AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />I' . <br />(Ages 10.54) - Yes F I No X <br />Yas Nd R <br />Yes No <br />28a. <br />286. DATE OF INJURY (Ala- Dry. Yr.) <br />280. HOUR OF INJURY <br />26d DESCRIBE HOW INJURY OCCURRED . <br />INJ <br />AwIdeM Undgertained <br />- y <br />.2% <br />St=be Pending - <br />2Be. INJURY AT WW <br />28L "ale. isDedryl fYm. sy& t WAoy, <br />LOCH -11014 'STREET OR F FJ1 NO. ' CRY OR 701M4 STATE <br />o Homicide Wmwagabon <br />Yee ❑ Nd ❑ <br />. <br />27a. DATE OF DEATH (Ala. Day Yrl <br />28a. DATE SIGNED (MO- Day Y rI <br />28b. TIME OF DEATH <br />September 8. 200 <br />11:00 omM <br />a� <br />ash <br />27b. DATE SIGNED IMd- Day. Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD. lA1a Day. Yr.) <br />28d. PRONOUNCED DEAD /Flour) <br />Set 3 <br />p. <br />1:10 am <br />M <br />Ee <br />_ M <br />$ a <br />27d. To the beet o1 my trowledge. deem omcurred 9the IbM, date and Plate and due ro dw <br />288. � a" IMF ' s) ' opKaon death ocaned g <br />�s)� <br />that <br />Dep Hall COA <br />8nd <br />and Tale ► <br />W. DIN TOBACCO <br />USE CONTRI BUTE TO THE DEATH? <br />We HAS ORGAN OR TISSUE DONATION �B.E�YE,N <br />CONSIDERED? <br />Sob WAS <br />YES NO <br />❑ YES . ❑ NO ® UNKNOWN <br />� YES U <br />NO <br />31. NINE AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) (TYPE orpt" <br />Michelle J Oldham, Dep Hall County Attorney, 231 S Locust, Grand <br />XZ& REGISTRAR <br />M. DATE FEET) BY REGISTRAR (Aft, Day. Yr.) f <br />SEP 11 2003 <br />v <br />F1,� Ilt,', v'�m o�Q`7 <br />� 3 !S <br />tty <br />NE <br />