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WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN *�E�H <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL 1 C{ __�� IS <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAB <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - <br />DATE OF ISSUANCE 20020706 6 - svapeR <br />JAN 2 2002 HEALTH A YETEM lIB -�-- TE11t- <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH 7N HUMAN SERy[�fDCANCE_AND SUu �1{T 14472 <br />CERTIFICATE OF DEATH - <br />F R5 <br />I1 MIDDLE LAST 2 SEX 3 DATE OF DEATH iMpnln DAY ✓M <br />OECEDENt NAME ' <br />Elmer Fay Hatch Male December 19, 2001 <br />CITYANDSTATEOF&RTH l,,.,ISA nameco AIIW 5a AGE Last &NtxNy UNDER YEAR UNDER DAY 6 DATE OF BIRTH IMMM. 1 9p 1J Day a�y. Yew) <br />p°1 5p,MOS. DAYS 5c. HOURS' MINS Au u$t . <br />tdell, Kansas b0 Be PLACE OF DEATH <br />SOCIAL SECURTIV NUMBER 1-1 HOSPITAL'. InCaaBM OTHER. NuSrrq Home <br />J7 -12 -6024 - ❑ EDOwpatienl ❑ aealence <br />I FACILITY -Nave GaT elr rim rnsrwnw. ryve srmel anO numeel ❑ DCA ❑ <br />omel (speonr <br />iffany Square_C nter <br />e <br />CITY TOWN OR LOCATIONOFDEATM B]. INSIDE CITY LIMBS Be COUNTY OF DEATH <br />rand Island, Nebraska [X] Np ❑ Hall <br />a. RESIDENCEsla 90. COUNTY 9c LIlV. iOWNOPLOCATION <br />- W. STREETANDNUMBEP Irrluelog zrP LOOeI i9e IrvSDECIn uMiS' <br />912 W 4th 68801 °° "° ❑ <br />Nebraska Hall Grand Island tle,, ,mef <br />o FACE Wlnle. Dlacc American lMlan. IL ANCESTRY '.e.9.Ilalian. Mevicart German aiq 12 ®MARWEO WIDOWED 3NAMEOF SPOUSE rll wile 0rrema <br />etcllSpecMl ISOemryl NEVER DrvpeCEO Arletta Rubs <br />White American MA RI I EDUCATION IScecMem nest9.aoecdnPlebal <br />I¢o KIND OF BUSINESS INDUSTFY _5 <br />- yn9 <br />IAA USUALDocu,AT1O, /Give ki�NOl wwx tlnna tlunnq m<rsl r EI°mnnla9Y {LI S %nnoa�v Y -121 GW.,ell aor5-r <br />A, Frnn rrlw IT rl 1e1101 1 L 1 <br />Tool & Die Machinist Leon Plastics <br />OTHER MIwL = - -- MAIDEN SURNAIAE <br />I6 FATHER <br />-NAME FIRS' <br />Ray Hatch <br />MIDDLE LAST <br />Elmer R M HF$' <br />Rachel A. Underhill <br />Ifi WAS DECEASED EVER IN US. ARMED FORCES' <br />1 INFORMANT NAME <br />(Yes nA a°nlrl 9a 'uv ° °9"a.a'am ealeed sanmeA Arletta Hatch <br />19O WFORMANi MAILINGADDRE55 ISTREETORRFO NO.. CITYORTOWN STALE. PP1 <br />912 West Fourth Grand Island, Nebraska 68801 - 21, cE FTEPYDP FEMAIOa. NAME— <br />��J 2ta MEle0D OF 06P051T'ON Dec. DATE <br />2 Atl NICE SIGNAtlIRE6 LICENSE NO Anatomical Board of the <br />�,emalM aaTy °A 'Dc 20, 2001 (State Of_Nebraska <br />❑ ❑ <br />21rt LEMETER YOECPEMA'OFV LOCATION L� YDH TOWN STATE <br />22a FUNERAL H ME NAME_ <br />Apfel- Butler- Geddes ❑ D ® Omaha, Nebraska__ _ <br />220 FUNERAL HOME AUDRFSS ISTPEET OR RE O. NO CTV OR TOWN. 51 ATE ZIP( <br />1123 West Second, Grand Island, NE. 68801 _ IMmvr6 En° nee an as <br />23 IMMED TE ..AU'E /Y�IVTER ONL, ONE CAUSE PER LINE FOR Is. 181 AN 11 <br />�V Z <br />` — <br />,.. I�� C�C O M 1 10 - Inte,.a', r. n pneel Ann °eAln <br />cl <br />OTHER SIGNIFICANT CONUIIII ..a/YP ^s'^^ " """ "'e' ° "' "" - "' -- PREGNANCY IN <br />DART C(D ��Y\ <br />II (Ages 10 54) <br />26A 26N. DATE OF INJURY IMO. Day yc( I 26c. HOUR OF INJURY 26n. DESC <br />❑ A¢rnent ❑ 01.0el —KY L <br />Smclee Vennm9 26e. INJURY AT WORK 26t oXlce e <br />H°mrnee Inves,gaJon Yas ❑ No ❑ -- <br />TTE OF DEATH FAA, Day Yc) <br />� m 2T6 DAtE SIGNE <br />oI yKlw+ea9e. seam �cca all me.aate an <br />29. ITC <br />❑ YES NO ❑ UNKNOWN <br />3t NAME AND AODRE550F CERTIPER (PHYSICIAN. COPCNE' <br />Dr. John J. Cannella ,729 <br />e,.. today 269. <br />iEREA 2< AUTOPSY 25 WAS CASE REFERRED iO MEDICAL <br />3 MONTHS? J EXAMINER OR CORONER' <br />J I I I Yes II Np I Ur le, <br />I Yes�NO��Ye, <br />INJURY OCCURRED <br />NO <br />Paz <br />ATH \_ s6Q� 26c PRONOUNCED DEAD IMO. DaY. Y,) 2Bn FRONDI <br />V M <br />91- <br />It <br />place eUe 1°me °$I "Oe He oasrsd e.ammanw aM'OI Invesugauon, In my opmmn <br />�- 1M1e lime. A. aM pace and cMewme cauee10 XRJP6 <br />(� L A)\, a S name and LT. 0- <br />9d HAS OR AN OR t155UE OUNATgN BEEN CONSIDERED 9pb WAS CONSENT GRANTED' ❑ <br />❑ . rl O <br />VE5 L�N YES <br />rN OR COUNTY ATTOPNEYI ITyce w Pnnp <br />h Custer Grand Island, Nebraska 68803 AR Mp 1,ay <br />7 2001 <br />9 <br />NO <br />?D DEAD W." <br />M <br />n occa.ed <br />AT <br />No <br />