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<br />Lot Thirty Six (36), Block Four (4), Pleasant View Addition
<br />Grand Island, Hall County, Nebraska
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<br />STATE OF COLORA OPR 11 2003
<br />HOLD TO LIGHT TO VIEW WATERMARK
<br />200307580 STATE OF COLORADO STATE FILE NUMBER
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S NAME (First, Middle. Last)
<br />Jack Dean
<br />4. SOCIAL SECURITY 5a. AGE -Last, I 5b. UNDER
<br />NUMBER Birthday (Years) bs
<br />506 -26 -8395 74
<br />8. WAS DECEDENT EVER IN 9a. PLACE OF DEATH (Check<
<br />U.S. ARMED FORCES?
<br />X Yes ❑ No HOSPITAL:
<br />❑ Inpatient 01
<br />9b. FACILITY NAME (If not institution, give street and number)
<br />2531 West Cove Creek Court
<br />10a. DECEDENTS USUAL OCCUPATION tOb. KIN[
<br />'Give kind of work done during most of wor�ing tile.
<br />bo not use retired)
<br />F
<br />Nebraska I Hall
<br />SYes 1O No O Yt
<br />No 68801 1 specify.,
<br />17. FATHER -NAME (First, Middle, Last) 1
<br />George Thomas Parker
<br />20fl. METHOD OF DISPOSITION
<br />❑ Burial ❑ Cremation ]J Removal from State
<br />❑Donation ❑Other(Specify)._.
<br />21a. SIGNATURE OF i NERAL DIRECTOR 0 ERSON AC
<br />YYY!!!JJ`/L/ C�,
<br />51- . UNDER 1 DAY 6."
<br />frs ' Mins AU
<br />OTHER
<br />ant ❑ DOA r ❑ Nursing 1
<br />9c. CITY, TOWN,
<br />Hig
<br />IESS/INDUSTRY
<br />Pipe Supply
<br />V, OR L ATI& Of4
<br />Island
<br />L
<br />2. SEX 3, DATE OF DEATH (Month, Day, Year)
<br />Male November 27, 2002
<br />IF BIRTH 7. BIRTHPLACE (City and State or Foreign e
<br />Day, Year) Country)
<br />t 13, 1928 Grand Island, NE
<br />xl Residence O OI
<br />)CATION OF DEATH
<br />nds Ranch
<br />Married
<br />I. STREETAND
<br />X16 East
<br />or Yes:- it yes, specify L,uban, Blaclf, While. siC..lSpe
<br />erto Rican, sit.)
<br />s
<br />White
<br />B. WfHEITMAXIM Middle, test (Maiden Narms" 1 19,
<br />1
<br />Catharine Rathman., D
<br />Op. PLACE OF DISPOStTION {Name of cemeterg cram #toy,, 0,
<br />other place)
<br />Grand Island Cemetery
<br />TNG AS SUCH : 21b. AME AND ADDRESS OF FAC1Ll
<br />Douglas
<br />arried, 12. SPOUSE (it wits, give maiden name)
<br />Donna Frandsen
<br />iER
<br />oenix Avenue
<br />. DECEDENTS EDUCATION (Specify only highest
<br />y0 redo completed) Elementary or secondary
<br />through 12) College 113 through 16 or 17 +) ,
<br />12
<br />VT -NAME and relationship to deceased.
<br />Parker- Wife
<br />1TION - City or Town, State
<br />Grand Island, Nebraska
<br />ry,
<br />Horan & McConaty Funeral Service /Cremation
<br />3201 S. ParkerrRoad, Aurora, CO zIP:80014
<br />22b. D EFILED(Md)r
<br />23. TTMB OFDE4l7t I 24. IQATE FRrOUNCED DEAD/ - J J 25. WAS CORONER NOTIFIED?
<br />Month' Dad / Ye Hour '. (Yes or No) - -_ -
<br />Unknown M November 27 2 2 0940 Yes
<br />TO BE COMPLETED ONLY BY CERTtFY1NG PHYSICIAN TO BE COMPLETED BY CORONER
<br />26. To the best of my knowledge, death occurred at the time, date and place, and doe to 27. On the basis of examination and /or investigation, in myopinion death occurred at the
<br />the causes) and manner as stated time, date and place, and due to the carise(s) end manner as stated.
<br />Signature , Signature
<br />1 28. DATE SIGNED (Month, Day, Yaw) 29. DATE SIGNED (Month, Day, YeaX
<br />2 December 02, 2002
<br />30. NAME, TITLE AND MAILING ADDRESS OF CERTIFIER /CORONER(Type /Print)
<br />3
<br />Wesley A. Riber, Deputy Coroner 4000 Justice Way Castle Pock, CO,- zip: 80109
<br />31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type/Print)
<br />4 32. MANNER OF DEATH 33a, DATE OF INJURY 33b. TIME OF 330. INJURY AT 33d DESCRIBE HOW INJURY OCCURRED
<br />. (Month, Day, Year) INJURY WORK?
<br />5
<br />3? Natural ❑Pending Investigation .�, ❑ Yes O No
<br />❑ Accident
<br />❑ Suicide O Undetermined
<br />Manner 33s. PLACE OF INJURY -Al home, farm, street, factory, office 331. LOCATION Greet and Number or Rum) Route Number, City, County, Stale)
<br />building, etc. (Specify)
<br />Cl Homicide
<br />34. IMMEDIATE CAUSE (ENTERONLYONE CAUSE PER LINE FOR (at (b), AND (c),! Do not enter mode of dying (e.g. Cardiac or Respiratory Arr"t)a)one. Interval between onset
<br />PART and death
<br />• I (a) Cardio-Respiratory Failurei
<br />s CONDITIONS DUE TO OR AS A CONSEOUE NCE OF Interval between onset
<br />IF ANY WHICH and death
<br />GAVE RISE TO (b) Heart Failure
<br />IMMEDIATE CAUSE
<br />STATING THE DUE TO OR AS A CONSEQUENCE OF - Interval between onset
<br />UNDERLYING CAUSE and death
<br />LAST (c) (_) Cardio Version
<br />PART OTHER SIGNIFICANT CONDITIONS- Conditiolns contributing to death but not related to cause in 35. AUTOPSY 36. IF YES were findings Considered
<br />It PART I (e.g, alcohol abuse, obesity, smoker). \ (Yes or No) in determining cause of death?
<br />Cerebro - vascular accident, prostate cancer. INO
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF T{��V.F OFFICIAL RECORD WHICH IS IN MY CUSTODY.
<br />1111�t DATEISSUED ��c 2002
<br />ADRS -18 1.89 (Rev. 1.91) RONALD S. HYMAN - -
<br />„_ rt STATE REGISTRAR
<br />5o, Do not accept unless prepared on security paper with engraved border, displaying the Colorado state _
<br />,. 3 seal and signature of the Registrar. PENALTY BY LAW, Section 25-2-118, Colorado Revised
<br />k Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use i
<br />i = any -vital statistics record. NOT VALID IF PHOTOCOPIED
<br />
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