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WHEN THIS COPY CARRIES Tl;E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST- s;IFGTllil WHJCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE
<br />rl AdLBY -0OF'ER
<br />9/2 9/ 2 0 0 4 '2 0 b 5 d 2 3 2 S AtSISTAI 0" REG VIUR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN Sf#06ES: SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES+EFANCE ACID &MPOI�
<br />vTTAL STATLSTIGS - (U1 J1
<br />CERTIFICATE OF DEAT14- - --
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX - 3. DATE OF DEATH /Month Oay, Year)
<br />John Douglas Clatterbuck Male October 26, 2003
<br />4. CITY AND STATE OF BIRTH /d not in U.S.A.. name country) 5a. AGE • Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year)
<br />Washington, D.C. Yrs.) 52 5b.M05 Dnvs so.HQUgs1 Mws. ,January 8,. 1951
<br />7. SOCIAL SECURYIY NUMBER Ba. PLACE OF DEATH
<br />507-58-8227 HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home
<br />8b. FACILITY - Name ((f not inse7uVon, give street and number) TT ❑ ER Outpatient X1 Residence
<br />2122 N Sherman Ave ❑ DOA ❑ Other(Specilvi
<br />5c. CITY, TOWN OR LOCATION OF DEATH ad. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Grand Island Yes M No ❑
<br />Ha 1-1
<br />Be. RESIDENCE � STATE 94. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER flnd)uding Zp Code) Be. INSIDE CITY LIMITS
<br />Nebraska Ha 11 Grand Island 2122 N Sherman ve . Yes [29 No []
<br />10. RACE - (e.g,, White. Black. American Indian. 11. ANCESTRY le.g.. Italian, Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE p( wi/e. give maiden namel
<br />etc.) (Specify) y,� (spedfy) NEVER DIVORCED Diane S a r r a i l l on
<br />White AT�►erican�. MA I
<br />14a. USUAL OCCUPATION /Give kind of work done drudng most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed)
<br />of working life, even d ratirao . . Elementary or Secondary (0 -121 Collage 11 -4 or 5 +1
<br />CurrIculum Developer Law Enforcement Traina g +
<br />16. FATHER • NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harold W. Clatterbuck Nancy Emma Yates
<br />18, WAS DECEASED EVER IN U.5, ARMED FORCES? 19a INFORMANT • NAME
<br />7se no, or unk.) (If y1. gtyeyleLand dates r�eejCyl�6� Diane Clatterbuck
<br />19b, INFORMANT MAILING ADDRESS j yy / (STREET OR R.F.O, NO., CITY OR TOWN, STATE, TIP)
<br />2122 N Sherman Avenue, Grand Island, Nebraska 68803
<br />20. WE�SAL��R - SIGNATURE d LICENSE 0. 21 e. METHOD OF DISPOSITION 214. DATE 21 c. CEMETERY OR CREMA ORY NAME
<br />❑ ❑ Central Nebraska
<br />n� Burial Removal October 29, 200 Centralon Nebraska
<br />-Oa.-Fu -4 AL FOMC- NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Klei a Funeral Holy ® Cremation ❑ Donation Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN, STATE, ZIP)
<br />3213 W North Front St. Grand Island, Nebraska 68803
<br />2 ..X` IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND )c)) Interval between onset and death
<br />PART
<br />I(,, Natural Causes unknown
<br />'DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and deals
<br />I
<br />_ (b)
<br />DUE TO, OR AS A CONSEQUENCE OF! Interval behveen asset and death
<br />I
<br />I
<br />(c) I
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A AUTOPSY WAS CASE REFERRED TO MEDICAL
<br />PART PgEGNANCV IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />I
<br />(Ages 10 -54) Yea No Yes Na Yes U No
<br />26a 26b DATE OF INJURY (Ma Day Ye) 28c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F Undetermined
<br />Suicide ❑ Pending
<br />26e, INJURY AT WORK
<br />M
<br />26f. PLACE QF INJURY - At Inge, farm. street. factory
<br />building,
<br />269. LOCATION STREET OR R,F, D, NO. CITY OR TOWN STATE
<br />Homicide Investlgatlon
<br />Ve9 ❑ No ❑
<br />o ice etc. (Speorry)
<br />27a. DATE OF DEATH (Mo.. Day. Yr)
<br />28A. DAYS SIGNED (Md.. Day. Yr.)
<br />/�10
<br />b. TIME OF DEATH
<br />-3)-63
<br />a rox 6:00 jm
<br />N 27b. DATE SIGNED (AA Day. YcJ
<br />27c. TIME OF DEATH
<br />a
<br />8c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />'Ad. PRONOUNCED DEAD (Hour)
<br />A
<br />October 26, 2003
<br />8 : 09 am M
<br />M
<br />H0,
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />g B
<br />2BB' On the basis of examination andror investigation, in my opinion death occurred at
<br />f \
<br />cause(s) stated.
<br />the time, date and place a d due to the cause(s) stated, Q
<br />(Signature and Title) ►
<br />(Signature and Title 1f' 1--. I 0 j a L°
<br />DID TOBACCO USE CONTRIBUTE 70 THE DEATH?
<br />3 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />b WAS CONSENT GRANTED?
<br />❑ YES In NO ❑ UNKNOWN
<br />❑
<br />YES NCI
<br />❑ YES NO
<br />1. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (T pe or P
<br />Sgt D Vitera, GIPD, 131 S Locust,
<br />Grand
<br />Island NE 68801
<br />32a, REGISTRAR ll
<br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />1144AN' !I.
<br />NOV - 4 2002,
<br />
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