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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF4/FAL-Til ,
<br />/T CERTIFIES THE BEL OW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON F/!.£ VW- M Th/E_S_T44TE
<br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STAT IST /CS, WHICH IS THE LEGAL= bEP#�RV Fi3i1L
<br />VITAL RECORDS. - - - --
<br />tAl D AJTEADN 197 2DO5O463b ST E-�YS_ .
<br />COOPER
<br />ASS /STAAfT
<br />STATE REGISTRAR
<br />LINCOLN, NEBRASKA ..- .__...... NEBRASKA DEPA$TAfEfVT O0FAftTH:-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT • NAME FIRST MIDDLE LAST
<br />2. SEX
<br />F DEATH /Month Day. Year)
<br />Harold Ardenell English
<br />Male
<br />[1.
<br />ary 10, 1997
<br />4. CITY AND STATE OF BIRTH Onot n USA.. name county)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH /Mont. Day. Year)
<br />5b. MOS I DAYS
<br />Sc. HOURS MINS.
<br />Wood River, Nebraska
<br />(Yrs.) 69
<br />April 01, 1927
<br />7, SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OFDEATH
<br />505 -22 -7645
<br />7
<br />HOSPITAL: © Inpatient OTHER: ❑ Nursing Home
<br />- . ITT
<br />811. FACILITY •Nam tenorinsMusun, giveshaerawnomber/
<br />❑ ER Outpatent ❑ Residence
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other tSpscdyi
<br />Be. CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Islas' .. -_ -. _- _._ _ __....__ ...__ _ _ ,
<br />t1to.
<br />Yea No
<br />Hall
<br />98. RESIDENCE • STATE
<br />9b. COUNTY
<br />Be. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Including Yip Cade)
<br />9e. IN 1D CITY LIMBS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />4228 Vermont Avenue, 68803
<br />❑X
<br />Yes No ❑
<br />10. RACE • (e.g.. White. Black, American Indian,
<br />11. ANCESTRY (e.g.. Malian, Mexican. German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE pt wile. give maiden name)
<br />NV%i el
<br />rMe'rican
<br />NEVER DIVORCED
<br />MARRIED Fj
<br />Eileen Sosselman
<br />14a. USUAL OCCUPATION (Give kMdo1 anvw done during most
<br />d tMe, Hunertvd)
<br />1411. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade Completed)
<br />-LD-U
<br />a Secondary (0 -12) Coll 11.4 or 5
<br />tai el
<br />aT)rkMg even
<br />Accountant/Personnel Manager
<br />Cornhusker Army Ammunition Pla
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Ernest L. English
<br />Mary Kearney
<br />T. 18. WAS DECEASED EVER IN U.S. ARMED FORCES7 19a INFORMANT-NAME
<br />07/23/1945-
<br />(Yea. no Or unk.l (if yes. give war and dates of aamiceal -
<br />Yes I World War II 08/28/, 1946 Eileen English
<br />1.9h. lNfQR]k!. pT. ._ _.__..MA1 LNGApt)AE58 _ . 1SIREE7 OBA D.yO-- yjLY173TOV/N STATE, 71a' _ ...... _
<br />4228 Vermont Ave, Gr d Island, Nebraska 68803
<br />0. SAL R -SIGN E ENSE N
<br />21 a. METHOD OF DISPOSITION
<br />216. DATE 21c.
<br />CEMETERY OR CREMATORY � NAME
<br />4107
<br />❑X Burial 1:1 Removal
<br />01/14/1997
<br />WestlaWn Memorial Park Cemeter3
<br />a. FUNERAL HOME -NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY 6R TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home
<br />❑ cremation ❑ Donation
<br />Grand Island, Nebraska
<br />2217. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIPI -
<br />1123 West Second Grand Island, Nebraska, 68801 -5899
<br />23.
<br />IMMEDIATE CAUSE
<br />(ENTER ONLY ONE CAUSE PER LINE FOR al. (b), AND (c))
<br />Interval between onset and death
<br />PREGNANCY
<br />y
<br />PART C }
<br />K) it) /� _ -_.
<br />(aDUE
<br />fl� �_ G 9, ���
<br />/y-� t�
<br />, '. ` �?
<br />`Day. `28c.
<br />TO. OR AS A CONSEOU
<br />- .- ...__.-
<br />1..._..., -S
<br />Interval t eMeti Onset and d-th
<br />28a.
<br />26b. DATE OF INJURY (Mo.. Yc/
<br />HOUR OF INJURY
<br />I
<br />F-1 ACCidert f Undetermined
<br />(b)
<br />I
<br />-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />ICI
<br />M
<br />Interval between onset and dean
<br />I
<br />PART SIGNIFICANT CONDITIONS • Conditions contributing to the death but rot related PART
<br />III IF FEMALE, WAS THERE A
<br />24 AUTOPSY
<br />I
<br />25, WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />y
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />`Day. `28c.
<br />(Ages 10.54) Yes NO
<br />Yes No
<br />Yes No
<br />28a.
<br />26b. DATE OF INJURY (Mo.. Yc/
<br />HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />F-1 ACCidert f Undetermined
<br />M
<br />❑ Sumide ❑ Pending
<br />260. INJURY AT WORK
<br />261, E �F
<br />6 %F INJURY %At hoglp, farm, Street, factory
<br />2%. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />F] Homicide Investigation
<br />Yes, ❑ No ❑
<br />deice �PecaY)
<br />27a, DATE OF DEATH (Mo.. Day. Yr)
<br />28a. DATE SIGNED (Alp.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />('rye
<br />127b.
<br />:-8
<br />+ a
<br />�
<br />DATE SIGNED tMo.. Day. Yr.)
<br />27c. TIME OF DEATH ��
<br />�
<br />28c, PRONOUNCED DEAD /Mc.. Day, Yr/
<br />28d. PRONOUNCED DEAD (Hour)
<br />- �y -tip
<br />d e� M
<br />M
<br />I
<br />I
<br />8
<br />,°.
<br />>S
<br />27d. To the best of my k oCCurred at and pla due to the
<br />Causes) stated. 7� \\
<br />28e. On the basis of examination and/or Inves"Ation, in my opinion death OCCurred at
<br />the eme, date and place and due to the cause(el stated.
<br />(Signature and Tidel ► or �"�t N`
<br />(signature and Ttla
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />3Da HAS ORGAN OR TISSUE DONATION BBE -EEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES �0 El UNKNOWN
<br />❑ YES 1]SI NO
<br />'1
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Prinij
<br />Dr. John J. Cannella, 729 N CusteA,.Prand Isla4, Ngbraska 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr./
<br />JAN 151997
<br />./
<br />Eileen English
<br />4228 Vermont
<br />Grand Island, NE 68803
<br />Lot 6, Block 2, in Capital Heights Third Subdivision, City of Grand Island, Hall County,
<br />Nebraska.
<br />
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