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LINCOLN, NEBRASKA HEAL TH AND HMNA N. 815".
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN Sl 1kri IS JqN. S[1PPORT
<br />VITAL STATISTICS ' `7.
<br />_ CERTIFIC_A_TE OF DEATH 10 1�
<br />r I DECEDENT - NAME FIRST MIDDLE �I -AST 2. SEX 3. DAI'L OF DEATH ,Month Day. Y'aar)
<br />James Anthony Moore Male November 10, 2001
<br />1 4 CITY AND STATE OF Wood River Nebraska 87 UNDER 1 YEAR UNDER I DAY 6 DAILUF BINN1 MU,fh 01 ✓earl
<br />_.
<br />' DAYS 5c. HOURS' MIN
<br />IH I'I lit not to US.A. name country) a.
<br />Ivry 1 Last Birthday Sb. MOF. I July 03,
<br />7. SOCIAL SFCUR'TIV NUMBER 8a. PLACE OF DEATH
<br />508 -12 --9369 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Horne
<br />tlp r'n{,,ILI I Y - Narne
<br />2403 W. 18th
<br />6t. CI I Y 7OWN OR LDCATIDN DF
<br />111 nut rns'nfuhurl, give s'IreNt .Irtd ""1161 ❑ ER Outpatient ® Residence
<br />❑ DOA ❑ Other /Soecd o
<br />Grand Island �Yas [�j No ❑ Hall
<br />9a. RESIDENCE -STATE 9b COUNIY 9c. Cl fY. TOWN OR LOCATION 9d. STREET AND NUMBFR llncl my tp ('udel 19e INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 2403 W 18th Yes &] No
<br />I D RACE )B.g., White. Black. American Indian_ I I, ANCESTRY le g Italian. Mex�Can. German. etcl 17 ® MARRIED ❑ WIDOWED 13 NAME OF SHOUSE tl wire. prve maiden more)
<br />etc) (Specify) I'u UYI NEVER DIVURCEU eata C. Kru man
<br />White American _ B Krug
<br />man
<br />USUAL OCCUPATION /Give A,ndorwork done during most 14b KIND OF BUSINESS INDUSTRY T 15. EDUCATION )Spec,ty only highest grade completed) --
<br />nr working htr , even d refired) F.lemantj! u, `-
<br />Department Manager Skagway Grocery�r, r.rr
<br />dory 10 121 C:nllege I1 ^ ......... .... ........_._....
<br />16 FATHER -NAME HHS1 MIC)Dt F LAS! �1, MOTHER FIRST MILIDLL MAIDFN SURNAME
<br />William Anthony Moore Ellen Kyan
<br />18. WAS DECEASED EVER IN U.S ARMED FORCES? 19a INFORMANT NAME
<br />IYe • r1o. or unk.) III yes. gwe war and dales- of services)
<br />�
<br />o Tom Moore
<br />- s
<br />lgb INFORMANT MAILING ADDRESS IS1 F1[ET OR R F D NO, CITY OR TOWN 1 A I C. ZIPI '
<br />4137 W. Capital Ave., Grand Island, Nebraska 68803
<br />_ _ __
<br />20 EMBAG 7UR�SLICI�NSENO 71a METHDODFDI$POS111UN 21 b. DATE 71 CEMETERY DN CHEMA(ORV NAME
<br />#1227 Burial ❑H.".", 11/13/2001 Westlawn Memorial Park Cem.
<br />22a. FUNERAL HOME - NAME 71d CEMETERY OR CREMATORY LOCATION (,ITY OR TOWN Si W1
<br />�pfel- Butler- Geddes Funeral Home ❑Ctemetlon ❑Donalon Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R. F.0 NO CITY OR TOWN. STATE, ZIPI W
<br />1123 West Second Street, Grand Island, Nebraska 68801 -5899
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la) . (bl, AND (c)) Interval between onset and dear,
<br />PART `
<br />....,
<br />DUE rO, OR AS A CONSEQUENCE OF rn� _
<br />I Inlarval a een onset and dP.art1
<br />I -
<br />(bl
<br />0tJF I U) UH Ay A L,ONSIEUULNUE UI '
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PART PREGNANCY IN THE PAST 3 MONTHS?
<br />(Ages 10 -54) Y95 a No Yes No
<br />26a 46b. DATE OF INJURY (Mo.. Day. Yr /26c. HOUR OF INJURY 2Ed. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined M
<br />'
<br />El suicide u pending 26e.. INJURY AT WORK 261. office PLACE Oi F INJURY /SAt�hcof 1. (arm, street. laetory � 26g. LOCATION STREET UH H.F.D. NO
<br />Homicide Investigation Yes ❑ NO ❑ rl'
<br />77a PATE OF pEATH /MO Day YrJ
<br />,.rt November 10,2001
<br />>- 27b. DATE SIGNED (Mo.. Day. YO 27c TIME OF DEATH
<br />g Novemb 12,200 6:30am _
<br />27d. To tho bogtofmy knowledge d h turn at the ime. to antl place and due m the
<br />Causes) stated. __�� rr,
<br />28a. DATE SIGNED (Mo Day Y(.l
<br />r 28c. PRONOUNCED DEAD IMO.. Day, Yr.)
<br />M
<br />Interval balweerl onset and dear,
<br />25. WAS CASE REFERRED TO MEDICAL
<br />=N ASE OR CORONER(
<br />Yes No .,- t -•
<br />CITY OR TOWN STATE
<br />26h IIMF OF DEATH
<br />M
<br />28d. PRONOUNCED DEAD /Hourl
<br />M
<br />;[ R S 28e. On the basis of examination and or investigation, In my opinion death occurred at
<br />, , - the time, date and place and due to the causefsl stated.
<br />? i DID TOBACCO USF CONTRIBUTE T HF DEATH' 36.a HAS ORGAN OR I ISSUE DONATION BFFN CONSIDERED' 30 b WAS CONSENT (THAN TELI'+
<br />❑ YES �NO ❑ UNKNOWN ❑ YES g0 _ YES ® NU
<br />31 NAME AND ADDRFSS OF CERTIFIER (PHYSICIAN, CORONER '5 PHYSICIAN OH COUNTY ATTORNEY( /Type or Print)
<br />Dr. Ryan D. Crouch, 800 A a GrIpJ41sla nd Nebraska 68803
<br />. �..
<br />32a. REGISTRAR 32D. DATE FILED BY REGISTRAR IMO.. Day. YrJ
<br />Nov 19 2001
<br />EAST HALF OF THF. NORTH 28 FEET OF LOT 3, AND THE EAST HALF OF LOT 1, BLOCK 20, SCARFF'S
<br />ADDITION TO WEST LAWN IN THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
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<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN.
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RR� D Flt€ PITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS"9�JAi;.iI/C15
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE
<br />NOV 19 2001 200503094
<br />ASSTa r
<br />tlp r'n{,,ILI I Y - Narne
<br />2403 W. 18th
<br />6t. CI I Y 7OWN OR LDCATIDN DF
<br />111 nut rns'nfuhurl, give s'IreNt .Irtd ""1161 ❑ ER Outpatient ® Residence
<br />❑ DOA ❑ Other /Soecd o
<br />Grand Island �Yas [�j No ❑ Hall
<br />9a. RESIDENCE -STATE 9b COUNIY 9c. Cl fY. TOWN OR LOCATION 9d. STREET AND NUMBFR llncl my tp ('udel 19e INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 2403 W 18th Yes &] No
<br />I D RACE )B.g., White. Black. American Indian_ I I, ANCESTRY le g Italian. Mex�Can. German. etcl 17 ® MARRIED ❑ WIDOWED 13 NAME OF SHOUSE tl wire. prve maiden more)
<br />etc) (Specify) I'u UYI NEVER DIVURCEU eata C. Kru man
<br />White American _ B Krug
<br />man
<br />USUAL OCCUPATION /Give A,ndorwork done during most 14b KIND OF BUSINESS INDUSTRY T 15. EDUCATION )Spec,ty only highest grade completed) --
<br />nr working htr , even d refired) F.lemantj! u, `-
<br />Department Manager Skagway Grocery�r, r.rr
<br />dory 10 121 C:nllege I1 ^ ......... .... ........_._....
<br />16 FATHER -NAME HHS1 MIC)Dt F LAS! �1, MOTHER FIRST MILIDLL MAIDFN SURNAME
<br />William Anthony Moore Ellen Kyan
<br />18. WAS DECEASED EVER IN U.S ARMED FORCES? 19a INFORMANT NAME
<br />IYe • r1o. or unk.) III yes. gwe war and dales- of services)
<br />�
<br />o Tom Moore
<br />- s
<br />lgb INFORMANT MAILING ADDRESS IS1 F1[ET OR R F D NO, CITY OR TOWN 1 A I C. ZIPI '
<br />4137 W. Capital Ave., Grand Island, Nebraska 68803
<br />_ _ __
<br />20 EMBAG 7UR�SLICI�NSENO 71a METHDODFDI$POS111UN 21 b. DATE 71 CEMETERY DN CHEMA(ORV NAME
<br />#1227 Burial ❑H.".", 11/13/2001 Westlawn Memorial Park Cem.
<br />22a. FUNERAL HOME - NAME 71d CEMETERY OR CREMATORY LOCATION (,ITY OR TOWN Si W1
<br />�pfel- Butler- Geddes Funeral Home ❑Ctemetlon ❑Donalon Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R. F.0 NO CITY OR TOWN. STATE, ZIPI W
<br />1123 West Second Street, Grand Island, Nebraska 68801 -5899
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la) . (bl, AND (c)) Interval between onset and dear,
<br />PART `
<br />....,
<br />DUE rO, OR AS A CONSEQUENCE OF rn� _
<br />I Inlarval a een onset and dP.art1
<br />I -
<br />(bl
<br />0tJF I U) UH Ay A L,ONSIEUULNUE UI '
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PART PREGNANCY IN THE PAST 3 MONTHS?
<br />(Ages 10 -54) Y95 a No Yes No
<br />26a 46b. DATE OF INJURY (Mo.. Day. Yr /26c. HOUR OF INJURY 2Ed. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined M
<br />'
<br />El suicide u pending 26e.. INJURY AT WORK 261. office PLACE Oi F INJURY /SAt�hcof 1. (arm, street. laetory � 26g. LOCATION STREET UH H.F.D. NO
<br />Homicide Investigation Yes ❑ NO ❑ rl'
<br />77a PATE OF pEATH /MO Day YrJ
<br />,.rt November 10,2001
<br />>- 27b. DATE SIGNED (Mo.. Day. YO 27c TIME OF DEATH
<br />g Novemb 12,200 6:30am _
<br />27d. To tho bogtofmy knowledge d h turn at the ime. to antl place and due m the
<br />Causes) stated. __�� rr,
<br />28a. DATE SIGNED (Mo Day Y(.l
<br />r 28c. PRONOUNCED DEAD IMO.. Day, Yr.)
<br />M
<br />Interval balweerl onset and dear,
<br />25. WAS CASE REFERRED TO MEDICAL
<br />=N ASE OR CORONER(
<br />Yes No .,- t -•
<br />CITY OR TOWN STATE
<br />26h IIMF OF DEATH
<br />M
<br />28d. PRONOUNCED DEAD /Hourl
<br />M
<br />;[ R S 28e. On the basis of examination and or investigation, In my opinion death occurred at
<br />, , - the time, date and place and due to the causefsl stated.
<br />? i DID TOBACCO USF CONTRIBUTE T HF DEATH' 36.a HAS ORGAN OR I ISSUE DONATION BFFN CONSIDERED' 30 b WAS CONSENT (THAN TELI'+
<br />❑ YES �NO ❑ UNKNOWN ❑ YES g0 _ YES ® NU
<br />31 NAME AND ADDRFSS OF CERTIFIER (PHYSICIAN, CORONER '5 PHYSICIAN OH COUNTY ATTORNEY( /Type or Print)
<br />Dr. Ryan D. Crouch, 800 A a GrIpJ41sla nd Nebraska 68803
<br />. �..
<br />32a. REGISTRAR 32D. DATE FILED BY REGISTRAR IMO.. Day. YrJ
<br />Nov 19 2001
<br />EAST HALF OF THF. NORTH 28 FEET OF LOT 3, AND THE EAST HALF OF LOT 1, BLOCK 20, SCARFF'S
<br />ADDITION TO WEST LAWN IN THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />
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