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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEIK IT CERTIRES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAAL STA j "_ C;k SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = A <br />DATE OF ISSUANCE <br />2 0 0 410 3 9 4- _: mm's. COOPER <br />AUG 9 2001 = - = .1XNTftATEREGISTRAR <br />LINCOLN, NEBRASKA #E4THAiV6 Ni;W#&CES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALXH AND 19JMAN SERVIE-'f f*ANCE AND SUPPORT <br />VITAL <br />rPuTTFTrATP (l nV.* TFT;- 01 08645 <br />1 DECEDENT -NAME FIRST MIDDLE LAST -.'_ -_ <br />2. SE%_ <br />3. DATE OF DEATH /Month Day Year) <br />M <br />= <br />y <br />4. CITY AND STATE OF BIRTH III not it USA.. name tountryl <br />Se. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Mawr. Day. Year) <br />', <br />5,. HOURS MINS <br />Grand Island, Nebraska <br />"fs1 50 so. <br />M <br />c_n <br />Ba. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />�t <br />CD -�i <br />p <br />rn <br />8b. FACILITY - Name (d not institution, give street and number) <br />102 Stellar <br />❑ ODA ❑ Other'Specvfy, <br />Z <br />7C <br />Be. COUNTY OF DEATH <br />� <br />Yes E No ❑ <br />C= <br />9a. RESIDENCE -STATE <br />9b. COUNiY - <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (NUutling ZP Code) - <br />9e..INSIDE CrITY LIMITS <br />C7 <br />Hall <br />Alda <br />rn � <br />-i <br />� M <br />p <br />fD <br />13. NAME OF SPOUSE /a wile. give maiden name) <br />(� <br />CA <br />NEVER DIVORCED <br />1 Lynda 'Soper <br />lte <br />� <br />O <br />USUAL OCCUPATION /Give kind of work dare during moat 11b. <br />CL <br />15. EDUCATION <br />:� <br />s <br />of working life, even it retired) <br />Production worker <br />PLastics manufacturing <br />ATHER - NAME FIRST MIDDLE UST 17. <br />[14 <br />° <br />Jv <br />u-I <br />-n <br />o - <br />s <br />' <br />QYesunkl Vie inamdat1970e 1972 <br />Lynda Paulk <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />102 Stellar Aldo NE 68810 <br />20. LMER - SIGNAT E ENO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY -NAME <br />z <br />® Burial ❑ Removal <br />7/30/01 <br />L 1 <br />a. FU RAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel Funeral Home <br />❑ D'enlittibn ❑ Do. <br />Wood River NE <br />Rt <br />411 West 11th P.O. Box 126 Wood River NE 68883 <br />Jr CD <br />F-A <br />=3 <br />�i1 <br />(b) <br />DUE TO. OR AS A CONSEOUENCE OF: Interval between onset and death <br />I <br />1 <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contrib tiN to the death but not related PART <br />111 IF FEMALE. WAS THERE A <br />24 . AUTOPSY <br />rn <br />3 <br />r D <br />EXAMINER OR CORONER? <br />II <br />(Ages 10-54) Yes n No <br />Yes No <br />Yes p No <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident n Undetermined <br />O <br />M <br />❑ Suicide F] Pending <br />26e. INJURY AT WORK <br />261 PLACEE OF INJURY - At Icon g /arm street factory <br />bxlding. etc. /Spec. <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Eloffice <br />Investigation <br />J <br />❑ ❑ <br />171 <br />D <br />Ca <br />CD <br />27a. DATE DEATH (MO.. Day. Yr.)O� <br />28a. DATE SIGNED (Mo., Day. YO <br />28b. TIME OF DEATH <br />C0 <br />( <br />0 0 <br />� <br />r� <br />N <br />.G <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD IMO.. DaY, Yc/ <br />28d. PRONOUNCED DEAD (Hour/ <br />�xa � <br />o <br />C ;'J1 ` <br />/ i;z 0 z \ <br />'J �� ^ <br />r( 1 jLi1 M <br />a� <br />8 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEIK IT CERTIRES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAAL STA j "_ C;k SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = A <br />DATE OF ISSUANCE <br />2 0 0 410 3 9 4- _: mm's. COOPER <br />AUG 9 2001 = - = .1XNTftATEREGISTRAR <br />LINCOLN, NEBRASKA #E4THAiV6 Ni;W#&CES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALXH AND 19JMAN SERVIE-'f f*ANCE AND SUPPORT <br />VITAL <br />rPuTTFTrATP (l nV.* TFT;- 01 08645 <br />1 DECEDENT -NAME FIRST MIDDLE LAST -.'_ -_ <br />2. SE%_ <br />3. DATE OF DEATH /Month Day Year) <br />Brent Jerome Paulk <br />Male <br />July 26, 2001 <br />4. CITY AND STATE OF BIRTH III not it USA.. name tountryl <br />Se. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Mawr. Day. Year) <br />Mos. DAYS <br />5,. HOURS MINS <br />Grand Island, Nebraska <br />"fs1 50 so. <br />May 3 1951 <br />7. SOCIAL SECURTIY NUMBER <br />Ba. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />506 <br />-66 -5811 <br />❑ ER Outpatient ® Residence <br />8b. FACILITY - Name (d not institution, give street and number) <br />102 Stellar <br />❑ ODA ❑ Other'Specvfy, <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Alda <br />Yes E No ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />9b. COUNiY - <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (NUutling ZP Code) - <br />9e..INSIDE CrITY LIMITS <br />Nebraska <br />Hall <br />Alda <br />1 102 Stellar 68810 <br />Yes ® No ❑ <br />10. RACE - (e.g., While. Black. American Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, etcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /a wile. give maiden name) <br />etc./ fSOer1!tly_ <br />1S0BC1 "tnglish <br />I <br />NEVER DIVORCED <br />1 Lynda 'Soper <br />lte <br />USUAL OCCUPATION /Give kind of work dare during moat 11b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed( <br />Ekmenta SBcaWary lO -121 CoNeg 11 -aa5-I <br />i 1 <br />of working life, even it retired) <br />Production worker <br />PLastics manufacturing <br />ATHER - NAME FIRST MIDDLE UST 17. <br />[14 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Maurice J. Paulk <br />Opal J. Mays <br />AS DECEASED EVER IN U.S. ARMED FORCES? <br />tga INFORMANT -NAME <br />QYesunkl Vie inamdat1970e 1972 <br />Lynda Paulk <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />102 Stellar Aldo NE 68810 <br />20. LMER - SIGNAT E ENO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY -NAME <br />® Burial ❑ Removal <br />7/30/01 <br />Wood River CemeterY <br />a. FU RAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel Funeral Home <br />❑ D'enlittibn ❑ Do. <br />Wood River NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE BPI <br />411 West 11th P.O. Box 126 Wood River NE 68883 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. IbI, AND (tp I Interval between onset and seam <br />P O /_. r <br />PART �i tS e tie �P-Y ` �V 1. 1 -. W S <br />al K <br />e DUE TO, OR AS A CONSEQUENCE OF i Interval between onset and death <br />(:CX x fi Morfif <br />(b) <br />DUE TO. OR AS A CONSEOUENCE OF: Interval between onset and death <br />I <br />1 <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contrib tiN to the death but not related PART <br />111 IF FEMALE. WAS THERE A <br />24 . AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />II <br />(Ages 10-54) Yes n No <br />Yes No <br />Yes p No <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident n Undetermined <br />M <br />❑ Suicide F] Pending <br />26e. INJURY AT WORK <br />261 PLACEE OF INJURY - At Icon g /arm street factory <br />bxlding. etc. /Spec. <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Eloffice <br />Investigation <br />J <br />❑ ❑ <br />Homicide <br />yes No <br />27a. DATE DEATH (MO.. Day. Yr.)O� <br />28a. DATE SIGNED (Mo., Day. YO <br />28b. TIME OF DEATH <br />( <br />0 0 <br />N <br />.G <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD IMO.. DaY, Yc/ <br />28d. PRONOUNCED DEAD (Hour/ <br />�xa � <br />o <br />C ;'J1 ` <br />/ i;z 0 z \ <br />'J �� ^ <br />r( 1 jLi1 M <br />a� <br />8 <br />M <br />g <br />~ c <br />< <br />27d. To the best of my knowledge. occurred at the lime, date and place and Idue to the <br />u <br />28e. On the basis of examination and !or investigation, in my opinion death occurred at <br />cause(s) stated. n A �l i A I ` , <br />a <br />the time. date and place and due to the causes) stated. <br />(Signature and Tit k)Y [�/\ ` `u / / <br />(Signature - and Title <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />1k YES NO ❑ UNKNOWN <br />YYYYYYANANN---- ^^^ ^^D <br />YES NO <br />❑ YES NO <br />31, NAME D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type a Print) <br />Pa L-e ; � ve G, « s ��� <br />o s cL <br />32a. REGISTRAR <br />b. DATE FILED BY REGISTRAR (Mo.. Day Yr.) AUG 8 2001 <br />U - <br />LEGAL DESCRIPTION: LOT 16, ARGO SECOND SUBDIVISION, IN THE VILLAGE OF ALDA, HALL COUNTY, NEBRASKA <br />