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Rev 11197 C C O O V T 0 V O N E td a) I ro V Z w E � C w in !� L LL 0.0 w a) N 7 Q Z LL ('7 C) 2004118 02 0 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS _ CERTIFICATE OF DEATH _FIRST k or,.! George B. Dilla 4 CITY ANOSTATE OF BIRTH Ianotin USA name Counlryl Sa ArF L Farwell, Nebraska IY rs 7 SOCIAL SECURTIY NUMBER UNDER 1 YEAR U 507 -20 -1672 _ 6. DATE OF BIRTH (Monf6. Day. Year) 8b FACILITY - Name (1I nnI msAluhpn, give sheet ano �IUmber( Sb MOS DAYS 5 St. Francis Medical Center 8c CITY TOWN OR IOCn itON OF DEATH Grand Island Jul 9 1925 9a RESIDENCE -$TA TF 9h COUNTY IT I( Nebraska Hall Gran 10 RACE le q. Whit. RI.,, American Indian 11 ANCF�T lY Ion Italia M,� ,an Germ etc 1 ISneuty) ISne� dYl White Polish German File USUALOCCUPATION (Give kind of work done during mna 14h MIND OF B, of work mo Ide. even A,ehredl ❑ DOA Other (Specrty, -- Machinist Auto 16 FATHER NAMF FIRST MIDDY I nGT George A. Dilla Sr. 9d STREETANDNUMBER f(nchdelg Zip Codel 9 LAST 2 2 SEX 3 3 DATE OF DEATH IMOnth Day Yead Jr. N November 28 2004 asl 8idhday U UNDER 1 YEAR U UNDER t DAY 6 6. DATE OF BIRTH (Monf6. Day. Year) Sb MOS DAYS 5 5c. HOURS MINS 79 J Jul 9 1925 Bit PLACE OF DEATH HOSPITAL a Inpatient OTHER ❑ Nursing Home ER Outpatient ❑ Residence ❑ DOA Other (Specrty, -- Bd INSIDE CITY LIMITS 8 8e COUNTY OF DEATH Yes kj No ❑ H Hall )WN OR LOCATION 9 9d STREETANDNUMBER f(nchdelg Zip Codel 9 9e INSIDE CITY LIMITS 68803 ❑ d Island 1 1405 Lafayette Y Yestj No ❑ an eta t t 2. ® MARRIED ❑ WIDOWED 1 13 NAME OF SPOUSE la wile give maiden namel NEVER DIVORCED G Garnette Kokes MARRIED U _ T8 WAS DECFASFI, FvFR IN US ARMF(I FORCES? I I i INFORMANT -NAME fye, , r unk 1 III yes Orve war and dates pl serv�casl No Garnette Dilla -- -- -- ---- -- — --- F9hINFURMANT MAILING AODRFSS (STREET ORRFn vn (-.nV OR TOWN STATE ZIP( 1405 Lafayette Grand Island, NI? 68803 7O IMHAI MIER SI(,,NA I I)RE A LICENSE NI I .i all RI DR C TF DISPOSI I ION 21b DAZE 21c CEMETERY OR CREMATURY NAME Service Not Embalmed �Riingi ❑Rnmrw, 11 -28 -04 Central Nebraska Cremation 22a FUNERAL HOMF NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Curran Funeral Chapel " "' "a''n" ❑ " " "a " °" Gibbon Nebraska 22b FUNERAL HOMF ADDRESS fSTREETORRFDNO CITY011 TOWN•If AFF LPI 3005 S. Locust St. Grand Island, NE 68801 ?�3 IMMEDIATE CAUSE IFtl l F R ONLY ONE CAUSE PER LINE FOR 1al (bt AND Icll I y Interval between onset and rleaur PART P/ /�� I tat )eV n'I m.• I, I Ot1E TO, OR AS A CONSEOUENCE OF I L Interval between ousel and dean /I/ I.- ,.ltk l-� i, +y`l I f .' - rrr►vk fJAI lbl DOE TO UN AS A CONSEOUENCE OF 1 Interval between onset and dead, I OTHER Se B1I111 ANT CONDITIONS Ca,dhnne cnnh IhA q tr� n�• d,•an, I��;� ��nt •�•Lm i PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO PART PREGNANCY IN THE PAST 3 MONTHS? E %AMINER OR CORONER? 11 r�T (� (Ages 1054) Yes No Yes No TAI Yes I I No 2fia 26b DAIS OF INJt1RY rkt Elm Y I ^r, UOI IR 1IF INJURY 26d. DESCRIBE HOW INJURY OCCURRED A—denl u I1•„Ieterm.ned -- t - - M U Swclde Ll q 26e INJURY AT WORK 261 PN Ae E QI IF I,URY At h -le. Ialm street factory 26g. LOCATION STREET OR R.F.D. NO. Hn tilde bvoshgahoo Yes ❑ No ❑ 2]a DATF OF DEATH fMP Day YrI ri' uys 2t DATF SIGNED (Mo. Day Yrl 7�c TIME OF DEAT IT 0012 AM To me best of my knowledge death occurred at the time dale and place and due to The causelsl staled. c R rf T IS, nature and Title ► Qyz 28a DATE SIGNED (Mo.. E u 28c PRONOUNCED DEAD IMo Day. Ycl a a > o CITY OR TOWN STATE 28d, PRONOUNCED DEAD (Horn) R 28e. On Me bjets sis of examination and o fnvesligalion, in my opinion death occurred at u � the time and place and due to the causelsl staled. ' 14 DID TOBACCO USE CONTRIB O THE DEATH? ( IT' ORGAN OR TISSUE DONATIONS 13EEEEN CONSIDERED? 13�b WAS CONSENT GRANTEDa ^ ❑ YES NO ,fq UNKNOWNS ❑ YES IC I NO (1 ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN f)II COUNTY ATTORNEY( (Type aPrinp Jeffrey K. King M.D. 729 N. Custer AV Grand Island, NE 68803 32a REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.l FOR VITAL STATISTICS USE ONLY M Place............. A ... ................. .... B..- _._ ( I .... .- D..... ..........................E.... ...........................Part ll ...................... TMV........................... NSC.___ ...._ ... ............................ _ -.__ . ... . .... ..... ............................................................................................................ Census Tract No. Work.............. . ....................... _- ..... .................................................................................................................. ............................... UC.__ .............. . ........... ................................................................................ ............................... s OTHER Se B1I111 ANT CONDITIONS Ca,dhnne cnnh IhA q tr� n�• d,•an, I��;� ��nt •�•Lm i PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO PART PREGNANCY IN THE PAST 3 MONTHS? E %AMINER OR CORONER? 11 r�T (� (Ages 1054) Yes No Yes No TAI Yes I I No 2fia 26b DAIS OF INJt1RY rkt Elm Y I ^r, UOI IR 1IF INJURY 26d. DESCRIBE HOW INJURY OCCURRED A—denl u I1•„Ieterm.ned -- t - - M U Swclde Ll q 26e INJURY AT WORK 261 PN Ae E QI IF I,URY At h -le. Ialm street factory 26g. LOCATION STREET OR R.F.D. NO. Hn tilde bvoshgahoo Yes ❑ No ❑ 2]a DATF OF DEATH fMP Day YrI ri' uys 2t DATF SIGNED (Mo. Day Yrl 7�c TIME OF DEAT IT 0012 AM To me best of my knowledge death occurred at the time dale and place and due to The causelsl staled. c R rf T IS, nature and Title ► Qyz 28a DATE SIGNED (Mo.. E u 28c PRONOUNCED DEAD IMo Day. Ycl a a > o CITY OR TOWN STATE 28d, PRONOUNCED DEAD (Horn) R 28e. On Me bjets sis of examination and o fnvesligalion, in my opinion death occurred at u � the time and place and due to the causelsl staled. ' 14 DID TOBACCO USE CONTRIB O THE DEATH? ( IT' ORGAN OR TISSUE DONATIONS 13EEEEN CONSIDERED? 13�b WAS CONSENT GRANTEDa ^ ❑ YES NO ,fq UNKNOWNS ❑ YES IC I NO (1 ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN f)II COUNTY ATTORNEY( (Type aPrinp Jeffrey K. King M.D. 729 N. Custer AV Grand Island, NE 68803 32a REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.l FOR VITAL STATISTICS USE ONLY M Place............. A ... ................. .... B..- _._ ( I .... .- D..... ..........................E.... ...........................Part ll ...................... TMV........................... NSC.___ ...._ ... ............................ _ -.__ . ... . .... ..... ............................................................................................................ Census Tract No. Work.............. . ....................... _- ..... .................................................................................................................. ............................... UC.__ .............. . ........... ................................................................................ ............................... s