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<br />WHEN TENS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, fT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIe$SEARO�_1T_,_'1111WICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE DF 0-P-t-oAllISSUANCE C COOPED
<br />AgaISTANT STAT 11 / 9/ 2 0 0 4 E REGISTRAR
<br />LINCOLN, NEBRASKA 200504736 HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HFALTH AND HUMAN SERVICES FMANM -AND S.UPPORpT
<br />VITAL C'F.RTTFTCATF. OF TIFATU __-04 12124
<br />FIRST MIDOLE LAST
<br />�1
<br />3. DATE OF DEATH /MOnm. Day, Year)
<br />7c_��
<br />Donovan Arnold Jenkins Jr.
<br />Male
<br />October 31, 2004
<br />4. CITY AND STATE OF BIRTH It not in U.S.A., name country)
<br />5a. AGE -Last Birthday
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTW /Month. Day. Year)
<br />M
<br />. Os. I DAYS
<br />So. HOURS I MINE
<br />Honolulu, Hawaii
<br />(YrsJ 74 Sb
<br />October 1, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />8s. PLACE OF DEATH
<br />508 -32 -1506
<br />HOSPITAL: Inpatient OTHER: Nursing Home
<br />-__� ❑ ❑
<br />_
<br />❑ ER Outpatient © Residence
<br />t 8b. FACILITY - Name (Irnot rrrsidutton, give street and number)
<br />Home: 1417 N. Wheeler
<br />❑ DOA ❑ Other
<br />'
<br />(Speidyl
<br />8c. CITY, TOWN OR LOCATION OF DEATH - ..._
<br />8d.. INSIDE CITY LIMITS
<br />ae. COUNTY OF DEATH ...
<br />Grand Island
<br />ve9 0 ❑
<br />Hall
<br />I
<br />No
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />go. STREET AND NUMBER /Including Zip Code)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1417 N. Wheeler 68801
<br />© ❑
<br />Yes No
<br />10, RACE - (e.g., White, Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etel
<br />12. © MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE /rl woe. give maiden name)
<br />etc.) (Specify)
<br />Whiteng''ish
<br />peci
<br />/Portuguese
<br />NEVER DIVORCED
<br />Irene Marie Frese
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Laborer
<br />Petroleum
<br />Elementary or Secondary (0 -12) College 11.4 or 5.1
<br />Equip ment
<br />12
<br />15. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Donovan Arnold Jeukins Sr
<br />Mercedes Thelma Souza
<br />CD
<br />EVER IN U.S. ARMED FORCES?
<br />1gd. INFORMANT -NAME
<br />(Yes. no. or unk.)
<br />>
<br />Yes
<br />Korean War 12/29/54
<br />Trene Marie Jenkins
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />1417 N. Wheeler Grand Island, Nebraska 68801
<br />T
<br />CD
<br />21. METHOD OF DISPOSITION
<br />216. DATE 270.
<br />CEMETERY OR CREMATORY NAME "
<br />;z Tr
<br />1
<br />Nov 3, 2004
<br />Central Nebraska Cremation
<br />Burial ❑ RempYal
<br />22a. FUNERAL HOM5 -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home
<br />® cremation ❑ Donation
<br />Gibbon, Nebraska
<br />M. FUNERAL HOME ADDRESS (STREET OR R,F.D, NO„ CITY OR TOWN. STATE, ZIP)
<br />1123 W. 2nd St. Grand Island, Nebraska 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (o)I Interval between onset and death
<br />PART I
<br />I (al
<br />rV,
<br />@1 I
<br />t
<br />W_
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE, WAS THERE A 24
<br />AUTOPSY
<br />25, WAS CASE REFERRED 70 MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTH57
<br />_T1
<br />�,.,...
<br />(Ages
<br />....r
<br />Yes NO
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /MO., Day. Yr,
<br />RY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />7 Accident ❑ Undetermined
<br />P..,.r
<br />M
<br />❑ Suicide Lj Pending
<br />266. INJURY AT WORK
<br />261. Pe g OF.INJURY -$At hop, farm. street, factory
<br />o ce ui d etc. ( r%
<br />25g, LOCATION STREET OR R.F,D, NO. CITY OR TOWN STATE
<br />0 Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />pea
<br />-
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />rtttttttttttttt�tw•�
<br />28b. TIME OF DEATH
<br />a
<br />October 31, 2004
<br />11-3-04
<br />approx. 3 : OOilm.
<br />276. DATE SIGNED /MO., pay. Yr.)
<br />C) r�
<br />28c. PRONOUNCED DEAD �. Dey Yr.1ai
<br />f _ �
<br />_.,.�
<br />NO
<br />g
<br />M
<br />1 0 -31 -04'
<br />4.20 a nt
<br />,B
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<br />27d. To the best of my knowledge, death occurred at the time, date and place and due to the
<br />28e. On the basis of exami on and•or v sagation, in pinion death occurred at
<br />cause(sl stated.
<br />° b
<br />the time, date and pla and du Causes) sta
<br />(Signature and Title ) ►
<br />I
<br />(Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />#AS CONSENT GRA TED?
<br />❑ YES ❑ NO ® UNKNOWN
<br />C P.'.
<br />❑ ES NO
<br />T\7
<br />°'
<br />LQ
<br />a
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<br />41
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<br />1 G+ 7
<br />(7
<br />WHEN TENS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, fT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIe$SEARO�_1T_,_'1111WICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE DF 0-P-t-oAllISSUANCE C COOPED
<br />AgaISTANT STAT 11 / 9/ 2 0 0 4 E REGISTRAR
<br />LINCOLN, NEBRASKA 200504736 HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HFALTH AND HUMAN SERVICES FMANM -AND S.UPPORpT
<br />VITAL C'F.RTTFTCATF. OF TIFATU __-04 12124
<br />FIRST MIDOLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /MOnm. Day, Year)
<br />7c_��
<br />Donovan Arnold Jenkins Jr.
<br />Male
<br />October 31, 2004
<br />4. CITY AND STATE OF BIRTH It not in U.S.A., name country)
<br />5a. AGE -Last Birthday
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTW /Month. Day. Year)
<br />M
<br />. Os. I DAYS
<br />So. HOURS I MINE
<br />Honolulu, Hawaii
<br />(YrsJ 74 Sb
<br />October 1, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />8s. PLACE OF DEATH
<br />508 -32 -1506
<br />HOSPITAL: Inpatient OTHER: Nursing Home
<br />-__� ❑ ❑
<br />_
<br />❑ ER Outpatient © Residence
<br />t 8b. FACILITY - Name (Irnot rrrsidutton, give street and number)
<br />Home: 1417 N. Wheeler
<br />❑ DOA ❑ Other
<br />'
<br />(Speidyl
<br />8c. CITY, TOWN OR LOCATION OF DEATH - ..._
<br />8d.. INSIDE CITY LIMITS
<br />ae. COUNTY OF DEATH ...
<br />Grand Island
<br />ve9 0 ❑
<br />Hall
<br />I
<br />No
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />go. STREET AND NUMBER /Including Zip Code)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1417 N. Wheeler 68801
<br />© ❑
<br />Yes No
<br />10, RACE - (e.g., White, Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etel
<br />12. © MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE /rl woe. give maiden name)
<br />etc.) (Specify)
<br />Whiteng''ish
<br />peci
<br />/Portuguese
<br />NEVER DIVORCED
<br />Irene Marie Frese
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Laborer
<br />Petroleum
<br />Elementary or Secondary (0 -12) College 11.4 or 5.1
<br />Equip ment
<br />12
<br />15. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Donovan Arnold Jeukins Sr
<br />Mercedes Thelma Souza
<br />18, WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />1gd. INFORMANT -NAME
<br />(Yes. no. or unk.)
<br />(If yes, give war and dates of services) 10/18/0
<br />Yes
<br />Korean War 12/29/54
<br />Trene Marie Jenkins
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />1417 N. Wheeler Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE d/LIC'ENSE NO J� �
<br />21. METHOD OF DISPOSITION
<br />216. DATE 270.
<br />CEMETERY OR CREMATORY NAME "
<br />;z Tr
<br />1
<br />Nov 3, 2004
<br />Central Nebraska Cremation
<br />Burial ❑ RempYal
<br />22a. FUNERAL HOM5 -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home
<br />® cremation ❑ Donation
<br />Gibbon, Nebraska
<br />M. FUNERAL HOME ADDRESS (STREET OR R,F.D, NO„ CITY OR TOWN. STATE, ZIP)
<br />1123 W. 2nd St. Grand Island, Nebraska 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (o)I Interval between onset and death
<br />PART I
<br />I (al
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />@1 I
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE, WAS THERE A 24
<br />AUTOPSY
<br />25, WAS CASE REFERRED 70 MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTH57
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No
<br />Yes NO
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /MO., Day. Yr,
<br />RY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />7 Accident ❑ Undetermined
<br />M
<br />❑ Suicide Lj Pending
<br />266. INJURY AT WORK
<br />261. Pe g OF.INJURY -$At hop, farm. street, factory
<br />o ce ui d etc. ( r%
<br />25g, LOCATION STREET OR R.F,D, NO. CITY OR TOWN STATE
<br />0 Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />pea
<br />-
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (W.. Day. Yr)
<br />28b. TIME OF DEATH
<br />a
<br />October 31, 2004
<br />11-3-04
<br />approx. 3 : OOilm.
<br />276. DATE SIGNED /MO., pay. Yr.)
<br />27c, TIME OF DEATH
<br />28c. PRONOUNCED DEAD �. Dey Yr.1ai
<br />28d. PRONOUNCED DEAD (Hcurt
<br />NO
<br />g
<br />M
<br />1 0 -31 -04'
<br />4.20 a nt
<br />,B
<br />° M Z�
<br />27d. To the best of my knowledge, death occurred at the time, date and place and due to the
<br />28e. On the basis of exami on and•or v sagation, in pinion death occurred at
<br />cause(sl stated.
<br />° b
<br />the time, date and pla and du Causes) sta
<br />(Signature and Title ) ►
<br />I
<br />(Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />#AS CONSENT GRA TED?
<br />❑ YES ❑ NO ® UNKNOWN
<br />[30.b
<br />❑ YES ® NO
<br />❑ ES NO
<br />,. ,...,- .., nv..n vr.,cnii'r .rn. uir, w'v .... r.'. - -1-1.r H.. UnrvtTl nypeor -it V
<br />Jerom E. Janulew•cz, Hall . Attorney, 231 S. Locust, G.T. NE 68801
<br />32a. REGISTRAR 326. DATE FILED BY REGISTRAR (Mo, Day. Yr.)
<br />V --
<br />
|