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® PO 0 n <br />C n = _ <br />-� m <br />�..I.Il.aaaaaaa� 0 Z n d ca CD <br />_ I � rn <br />m� a a <br />CD -" <br />00 6- 01 -- ri d <br />CD = .� ? cf) <br />Cn <br />■Ire �' � <br />O <br />c� <br />WHEN THIS COPYCARR/ES THE RAISED SEAL. OF THE NEBRASKA HEALTH'AND HUMAN SERVICES, <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RgQOR QN FIC MYI H <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST SECTION, h` <br />THE LEGAL: DEPOSITORY FOR VITAL RECORDS. <br />f:.,. f <br />DATE OF ISSUANCE O O 5 O $ 9 -t 04i a <br />JUL 2 S 1998 ASS /l/tN�TSATEC+,i�TRAR <br />LINCOLN, NEBRASKA HEALTH AND NANERVICE <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV >~5� UP T <br />VITAL STATISTICS ¢- <br />CI~RTIFICATE OF DEATH <br />I DECEDENT.NAME FIRST MIDDLE LAST 2 SEX 3. 'OATE4W DEATH IMdon Day.'yead <br />Clarice Annette Allely Female July 14, 1998 C�ddr�]jl <br />4 CITY AND STATE OF BIRTH /Knot in U.S.A. name 00unCy! 58. AGE " Last dlrdWWRY UNDER 1 YEAR <br />UNDER 1 DAY 8. DATE OF BIRTH !MO h(l -Day. Yead H <br />IYrs.I Sb, MOS I DAYS 5c. HOURS' MINS. <br />Lincoln, Nebraska 82 May 26, 1916. <br />7 SOCIAL SECURTIY NUMBER Bd. PLACE OF DEATH <br />861-70-1504 HOSPITAL ❑ Inpat am OTHER ❑ Nursing Fbma <br />Bb FACILITY -Name V 1,. m�61rea/aM numbs/) ❑ ER Ou1P01iM1 � Residence <br />2617 Brahma ❑ DOA ❑ Other(Specdyl '00 <br />tic, CITY ' TOWN OR LOCATION Of: DEATH 6d. INSIDE CITY LIMITS So COUNTY OF DEATH <br />Grand Island Vet [S] No El Hall <br />9a RESIDENCE " STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION ad. STREET AND,NUMBER (Inchx uLVZV Code/ 9O INSIDE CITY LIMITS <br />Nebraska Hall Grand Island 2617 Brahma, 68801 yet ❑X NO ❑ (/�� <br />10 RACE - (e.g.. White, BIaCk. American Indian. 11. ANCESTRY le.g•. Italian, Mexican. Garman. alcl LP, 12. [K MARRIED ❑ WIDOWED 13. NgME OF SPOUSE (n wile. 17n'a maiden name) l 1 <br />1 pechyl NEVER DIVORCED Ralph Allel y <br />�ViiI`I el =erican r*� <br />14a. USUAL OCCUPATION (Gwe kpajd work done draep mod( � 144. KIND OF BUSINESS INDUSTRY �'1 _ j-j 15. EDUCATION (Specify Only mghast grade c0- Plaledl k <br />d wLvk v klft even d retired/ CUv ElemenllayrY or Secondary (0,121 College 11 4 015-I <br />Bookkeeper Jewelr Store , f <br />16 FATHER -NAME 'FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />�1 <br />Clyde C. Pinkerton Bertha Corgi a <br />It WAS DECEASED EVER IN U.S. ARMED FORCES? tea INFORMANT - NAME <br />IVab o. w unk.l III yes. gwe wsr and n81et d nervicasl 7 <br />No Ral h Allel <br />19b INFORMANT MAILING ADDRESS ISTREET OR R.F.P. NO., CITY OR TOWN. STATE, 7JP) <br />2617 Brahma, Grand Island, Nebraska 68801 <br />20.E M�SIGN URE 8 LICE NO, 218 METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME <br />❑X Burial ❑ Removal 07/17/1998 W uka Cemetery <br />. FUNERAL HOME " AMC 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Iln <br />Apfel- Butler - Geddes. Funeral Home ❑Gremalgn ❑oonawn Lincoln, Nebraska ri <br />UNERAL HOME ADDRESS (STREET OR P.F.P. NO., CITY OR TOWN. STATE, TIPI v <br />1123 West Second Grand Island, Nebraska, 68801 <br />tleanh <br />I I <br />IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR lal. Ibl. ANP Icll interval between Onset one <br />let <br />I <br />I InteNal between onset and death <br />DUE 70.OR AS A CONSEQUENCE OF: I rye F`1 <br />W4 IG -ail <br />lot <br />I interval betwa6n onset arq seam H � <br />DUE Tq. OR AS A CONSEQUENCE OF' I FRi, <br />O7WER SIGNIFICANT CONDITIONS Canditi0n6 contibuang to the death but not related PART III IF FEMALE. WAS THERE A 2A AUTOPSY' g6. EXAAACINEA OR CORONER MEDICAL <br />Ic' PART " PREGNANCY IN THE,PAS! 7 MONTHS? <br />q <br />(Age s IO.5411 Vea 'No Yes No YeS NO <br />26a 286. DATE OF INJURY /Adp.. Day. YO 26c HOUR OF INJURY 266. DESCRIBE HOW INJURY OCCURRED <br />❑ Acadant Undetermined M Fri <br />'SwC-de Pending 26e� INJURY AT WORK 281. PLACEE ��F� INJURY - t how /arm. street. laciory 268. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE v,.� <br />❑ ❑ dfica bwtdutg etc. ISpcM'/ • <br />Homre-de Investigation Yet ❑ No ❑ <br />27a DATE OF DEATH (Mo.. Day Yrl 2 . DATE SIGNED /Ado.. pay. Yr.) y.7 294. TIME OF DEATH H <br />3 (J alb. <br />S 0 V <br />�S $ gC. RONp N ED R AD lMa. Day, Ycl '. 2Btl� PRONOUNCED DEAD /Howl <br />27b DATE SIGNED /Ado.. Day. yr/ 27c TIME OF DEATH ' S$ €,�i1 � <br />n1 ,• M Px <br />,3 27d To the best d my knowledge, death occurred it th0 tins, dg10 dud place and duo t0 the 28e. On t baala d examination andta Inv9slig twn, in my Opinion in Curled at <br />causal51 Slated. � the time, dale and piece and due 10 the 0 alsl Salted. <br />nature and Title <br />Sr nature and Title <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 90.4 S CONSE NTED? <br />❑ YES ❑ NO 1� UNKNOWN <br />❑ YES U NO YES R1, NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI hype or ✓sdet) <br />32a: O15TRAR 32b. RE DATE FILED BY EGISTRAR IRUL 12 1998 <br />M'P <br />