200202881 - Laserfiche WebLink

Browse

i, v �r J %C L G ` C' M T 2 D Z M Cn 0 n z x , Lot Seven (7), in Block Fifteen (15), Baker's Addition To the City of Grand Island, Hall County, Nebraska. WHEN THIS COPYCARR1ES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMANSERVICES SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRp - THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTW-TJ THE LEGAL DEPOSITORY FOR VITAL RECORDS. wli TE OF ISSUANCE MAR 4 2002 200202881 I pr TA _ LINCOLN, NEBRASKA HEALTH AND NI/M�iI SEf STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S�XIg$S.A;{D SUP VITAL STATISTICS r (� CERTIFICATE OF nFAT7 -I _ __ 0 02017 I. DECEDENT NAME FIRST MIDDLE LAST 2. SE% 3. DATE OF DEATH IMOnM Day Yearl Douglas Chester Clark Male February 19, 2002 <CITY AVID 6TgTE OF BIRTH Iniq'n 050. rlenre cOUnhyl 2 D UNDER YEAR UNOERI DAY v o - sc HOURS MINS Columbus, Nebraska f9 June 28, 1922 ]. SOCIAL SECURTIY NUMBER a 508 -14 -8094 n 2 ❑ ER ONpa.m ❑ Raardace 3 = ❑ We ❑ CITY TOWN OR LOCATION OF DEATH &. INSIDE CITY LIMITS &. COUNTY OF DEATH Grand Island Yx © NR ❑ Hall Se RESIDENCE - STATE 9d. COUNTY 9c. CITY. TOWN OR LOCATION SO. STREETANDNUMBER prcmarlg Zp CPea) & INSIDECITYLIMI Nebraska Hall Grand Island 2016 W. 1st St. 68801 YxE Na [ 10. RACEle9, WIIiM. BMC4. American Mian. 11. ANCESTRYIeg.. Aalian. Mencan. Gm+nen. exl 12 MARRIED ❑WIDOWED 13. NAME OF SPOUSE (n erM glremfHen narmJ IF Span ite Biwdyl American NEVER DIVORCED MARRIED Bessie Duerin tea USUALOCCUPATION lGrveemdd WwAaYVwdC„lgmxd ICE KIND OF BUSINESS INDUSTRY 16. EDUCATION ISI>aCiry ally NgNea guide compbMdl aAreA w, aredy"ree l Safety Engineer C FT ElemeMeryo OI'tlary 10121 Cabge ll J Or 5 -I t &FAYHER - NAME FLESH MIDDLE UST pMOTHER FIRST MIDDLE MAIDENSURNAME Chester Clark Ethel Douglas IS WAS DECEASED EVER IN US. ARMED FORCES? I" INFORMANT NAME FT' + 3 s: -194 0 -30 -1945 Bessie Clark o r D - cn a r✓ u', R o vl n ' CID Cn 1 rn Lot Seven (7), in Block Fifteen (15), Baker's Addition To the City of Grand Island, Hall County, Nebraska. WHEN THIS COPYCARR1ES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMANSERVICES SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRp - THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTW-TJ THE LEGAL DEPOSITORY FOR VITAL RECORDS. wli TE OF ISSUANCE MAR 4 2002 200202881 I pr TA _ LINCOLN, NEBRASKA HEALTH AND NI/M�iI SEf STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S�XIg$S.A;{D SUP VITAL STATISTICS r (� CERTIFICATE OF nFAT7 -I _ __ 0 02017 I. DECEDENT NAME FIRST MIDDLE LAST 2. SE% 3. DATE OF DEATH IMOnM Day Yearl Douglas Chester Clark Male February 19, 2002 <CITY AVID 6TgTE OF BIRTH Iniq'n 050. rlenre cOUnhyl Se. AGE -LeM Birl'Oay UNDER YEAR UNOERI DAY 6. DATE OF BIRTH IMMM. Day Vearl fie MOs � DAYS sc HOURS MINS Columbus, Nebraska f9 June 28, 1922 ]. SOCIAL SECURTIY NUMBER Be PLACE OF DEATH 508 -14 -8094 HOSPITAL mparredn OTHER Nursnq Home ❑ ❑ ER ONpa.m ❑ Raardace Bp. FACILITY -Name (nrgrinsNN.m.gia.,VAhy~) St. Francis Medical Center 16c. ❑ We ❑ CITY TOWN OR LOCATION OF DEATH &. INSIDE CITY LIMITS &. COUNTY OF DEATH Grand Island Yx © NR ❑ Hall Se RESIDENCE - STATE 9d. COUNTY 9c. CITY. TOWN OR LOCATION SO. STREETANDNUMBER prcmarlg Zp CPea) & INSIDECITYLIMI Nebraska Hall Grand Island 2016 W. 1st St. 68801 YxE Na [ 10. RACEle9, WIIiM. BMC4. American Mian. 11. ANCESTRYIeg.. Aalian. Mencan. Gm+nen. exl 12 MARRIED ❑WIDOWED 13. NAME OF SPOUSE (n erM glremfHen narmJ IF Span ite Biwdyl American NEVER DIVORCED MARRIED Bessie Duerin tea USUALOCCUPATION lGrveemdd WwAaYVwdC„lgmxd ICE KIND OF BUSINESS INDUSTRY 16. EDUCATION ISI>aCiry ally NgNea guide compbMdl aAreA w, aredy"ree l Safety Engineer Cornhusker Ammunition Plat ElemeMeryo OI'tlary 10121 Cabge ll J Or 5 -I t &FAYHER - NAME FLESH MIDDLE UST pMOTHER FIRST MIDDLE MAIDENSURNAME Chester Clark Ethel Douglas IS WAS DECEASED EVER IN US. ARMED FORCES? I" INFORMANT NAME xb wWNa I Ig Yx, .ySadd ry x 14 s: -194 0 -30 -1945 Bessie Clark 2016 W. 1st St., Grand Island, NE. 68801 2&. HOUR OF INJURY 2g. EMBLILMER- SIGNATUR a LICENSE NO ❑ AcClderY UMelemxred 2L.MET.GFLI ST.Nl�','eCDAT' M 21C. CEMETERY OR CREMATORY -NAME 2fie. INJURY AT WORN Yx ❑ No[:] -4/22 ®Burial ❑R. 22 2002 Westlawn Memorial Park 22.. FUNERALHOM NAME M 2]p. GATE SIGNED .{b.� V� METERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes M PRONOUNCED DEAD (HOurl ❑ONeebn ❑F � � M Grand Island, Nebraska 22 E. FUNERAL HOME ADDRESS (STREET OR R.F. D. NO CITY OA TOWN. STATE. BPI Ma HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Mb WAS CONSENTGRANTED? ❑ YES ❑ NO UNKNOWN 1123 West Second, Grand Island, NE 68801 I E GnoJ[ (ENTER ONLY ONE CAUSE PER LINE FOR eat INI. AND IC Interval tedeeen ousel aM death PAmI � ''�J D I (n1 PART OTHER SIGNIFICANT CONDITIONS-CpbiMds codbiMalg b lM dert LOOK Needed PAM II n.` A. •. y,��S PREGNANCY r�R�L III IF FEMALE. WAS THERE A 2a AUTOPSY 25. WAS CASE REFERRED TO MEDIC IN THE PAST 3 MONTHS? E %AMMEROR CORONER'+ Laurie 105a1 Yes No Yx NO Yes No 26a 26E. DATE OF INJURY (ME, Day YCI 2&. HOUR OF INJURY 260. DESCRIBE HOW INJURY OCCURRED ❑ AcClderY UMelemxred M Suicide PedNidp Hom¢ide ImeWUelpn 2fie. INJURY AT WORN Yx ❑ No[:] 261. PIACEOFI XURY /AIIIglq, larm. meet. tacbry 26g. LOCATION STREET OR RFD. NO CITY OR TOWN STATE OoRR�nle Ne�MaIbdIM�1IgFSSKKOaMM�I Da DATE OF DEATH (MO YU 28a DATE SIGNED IAb. Day Yr" EST TIME OF DEATH _j M 2]p. GATE SIGNED .{b.� V� 2]c TIME OF DFATM K k 2 &. PRONOUNCED DEAD dA,. Day Vie M PRONOUNCED DEAD (HOurl O � � M M 27d °� Ga9lIi1w,MWTw . M E OX10 the WIF e am OOei M a 1MIedelete a LM Y [IBCMri ba} M NQtl N/N b alleM x talpd6a94106M1 1 ain a kmdy . mrw 2g. BID TOBACCO USE (CONTRIBUTE TO THE DEATH? Ma HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Mb WAS CONSENTGRANTED? ❑ YES ❑ NO UNKNOWN ❑ YES ® NO ❑ YES © NO Karuna S. Gaddam M.D. V.A. Nebraska- Western Iowa Health Center, Grand Island,