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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORa"BILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN_SERWCES SYSTEM, VITAL STATISTlESSEC17ON, WW ti IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUL .`� 12001 0050 45 *C�
<br />LINCL NEBRASKA HEALTHAND'i�SU1f�ANSERVICESO s"
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FACT .AND'AWPORT
<br />VITAL STATISTICS (� j 1
<br />CERTIFICATE OF DEATH J
<br />_ . _._. _ - -...
<br />1 nFrb,t;Nr n +
<br />iFx 3 pAI, )F u FAn v, 1111• ,.n he.a�
<br />NAMI Ia;T nDler InST I
<br />I
<br />Harold Irvin
<br />—.
<br />17 AND STATE Of tlIHI H 'u nr,n, L' ; 1 name uunrrN �.
<br />Bassett, Nebraska
<br />I Sf)I,;IAL SCCIJ FI I'iV Nl1MtlLH
<br />506 34 8695
<br />Htr I A(;II II Y . N:1nle W'" r, 15larrt,Un, give 151 /ecy rn,:f number(
<br />414 N. Cedar Street
<br />- -- -- .... .... .. ..._ -
<br />Rc -N
<br />:V TOWNOn LOCATION ',)- DEATF•
<br />Grand Island
<br />McCullough Male July 20. 2001
<br />, -0 AGE La51B „thdly IINDF.RI YFAR UNDEn l DAY —� n D Kar l
<br />UAIL OF RIH•H IMowh „ l
<br />'Yrh, Sh M01; UAYti il:. HOURS MIN,,
<br />._66 ----- -!.... October 3, 1934
<br />di PI-AC F. OF DEATH
<br />HOSPITAL ❑ 111111101_1 OTHER LJ N, Ho"”,
<br />❑ �n OWpalient CX� Heyldenre
<br />6, IN.�IUL (.IfY LIMII'.� ,1(: (:i)l1NTV Uf UEAIH
<br />Ye, No ❑III Hall County
<br />9i: - ST11ECT11 NONtJNRiE- 1nC,u(nnry21pLc47C1 -�� Imo,
<br />F1 kk LJ
<br />Nebraska Hall_ Grand Island 414 N. Cedar St. , 6$$01 _Ye.S No
<br />10 RA(:F leg.. Whlle, Rlar.k Amen... Ind ", 11 AN[.FSTRV le q Italian Mex:rnn German. etch 17 ® MARRIED l l WIDOWED 13 NAMF OF SPOUSE :r(wrfe g,ve ma,lYen "'me)
<br />'1 '.SUe,:11yI IS{,t "fyI NEVER UIV11111.FU
<br />White Trish ❑ Carolyn Greig
<br />— _ - -- ' - -- - - -- MAH HILD
<br />14a '. J1,UAI, OCCUPATION (;me k,nn n/ — 1, luring 11,15, ,3h K IND OF BUSINESS INDU...;TRY rfiall ` EUCATION '1h c.fy lnly n�ghe, granerumnlelr'nl
<br />or wurk,ng 1,10 even d reared) nr • e o,, ary .0 121 Coneys I a o, Clerk Retail Grave
<br />18 FATHER NAME FIRST MIDDI., F" [AST 1 17 MOTHER FIRST MIDDLE MAIDEN Sl.1RNAME
<br />_ (Dec.) Henry Earl Korea I
<br />18 N/A`, 0FCFASFD EVER IN US ARMED F']RCFS° Korea 'II rBa INFORMANT NAME
<br />Yesrhxl lib rya, :)t yry 150 -1 1 -1957
<br />_ Carob
<br />19h NFORMANT MAn-INO AI)DPFSS ISTnEFT OR P. F n No CITY OR TOWN, STATE ZIPI
<br />Dec.) Helen Mae Fleming
<br />414 N. Cedar Street._
<br />Grand
<br />-- Island
<br />Nebraska 68801
<br />'::FMF.
<br />20 F .MHAI,MF.R 51(iNAiIIRFhIICFN,SF (r
<br />:7' i METHOD OF
<br />DISPOSITION : ?1�ATF
<br />121,. I'ERY OR CHLMn(UHY NAME ..
<br />�
<br />- -- I ` ,
<br />tlur�al
<br />Jul 25
<br />2001 IGrand Island City Cemetery
<br />YI.'�R(INER AL HOME NAME
<br />IS,gnalure and T tl I 0
<br />1 210 CFMFTERY OR CREMATORY
<br />LOCATION 11 rY OH TOWN ^STATI'
<br />Kleine Funeral Home
<br />El Cremation
<br />❑ Dpnaiip
<br />Grand Island, Nebraska
<br />W C its
<br />E
<br />nn
<br />❑ 'E5 L_-] NO ® UNKNOWN
<br />❑
<br />YES K, NO
<br />❑ YES
<br />NO
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<br />Cm
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORa"BILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN_SERWCES SYSTEM, VITAL STATISTlESSEC17ON, WW ti IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUL .`� 12001 0050 45 *C�
<br />LINCL NEBRASKA HEALTHAND'i�SU1f�ANSERVICESO s"
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FACT .AND'AWPORT
<br />VITAL STATISTICS (� j 1
<br />CERTIFICATE OF DEATH J
<br />_ . _._. _ - -...
<br />1 nFrb,t;Nr n +
<br />iFx 3 pAI, )F u FAn v, 1111• ,.n he.a�
<br />NAMI Ia;T nDler InST I
<br />I
<br />Harold Irvin
<br />—.
<br />17 AND STATE Of tlIHI H 'u nr,n, L' ; 1 name uunrrN �.
<br />Bassett, Nebraska
<br />I Sf)I,;IAL SCCIJ FI I'iV Nl1MtlLH
<br />506 34 8695
<br />Htr I A(;II II Y . N:1nle W'" r, 15larrt,Un, give 151 /ecy rn,:f number(
<br />414 N. Cedar Street
<br />- -- -- .... .... .. ..._ -
<br />Rc -N
<br />:V TOWNOn LOCATION ',)- DEATF•
<br />Grand Island
<br />McCullough Male July 20. 2001
<br />, -0 AGE La51B „thdly IINDF.RI YFAR UNDEn l DAY —� n D Kar l
<br />UAIL OF RIH•H IMowh „ l
<br />'Yrh, Sh M01; UAYti il:. HOURS MIN,,
<br />._66 ----- -!.... October 3, 1934
<br />di PI-AC F. OF DEATH
<br />HOSPITAL ❑ 111111101_1 OTHER LJ N, Ho"”,
<br />❑ �n OWpalient CX� Heyldenre
<br />6, IN.�IUL (.IfY LIMII'.� ,1(: (:i)l1NTV Uf UEAIH
<br />Ye, No ❑III Hall County
<br />9i: - ST11ECT11 NONtJNRiE- 1nC,u(nnry21pLc47C1 -�� Imo,
<br />F1 kk LJ
<br />Nebraska Hall_ Grand Island 414 N. Cedar St. , 6$$01 _Ye.S No
<br />10 RA(:F leg.. Whlle, Rlar.k Amen... Ind ", 11 AN[.FSTRV le q Italian Mex:rnn German. etch 17 ® MARRIED l l WIDOWED 13 NAMF OF SPOUSE :r(wrfe g,ve ma,lYen "'me)
<br />'1 '.SUe,:11yI IS{,t "fyI NEVER UIV11111.FU
<br />White Trish ❑ Carolyn Greig
<br />— _ - -- ' - -- - - -- MAH HILD
<br />14a '. J1,UAI, OCCUPATION (;me k,nn n/ — 1, luring 11,15, ,3h K IND OF BUSINESS INDU...;TRY rfiall ` EUCATION '1h c.fy lnly n�ghe, granerumnlelr'nl
<br />or wurk,ng 1,10 even d reared) nr • e o,, ary .0 121 Coneys I a o, Clerk Retail Grave
<br />18 FATHER NAME FIRST MIDDI., F" [AST 1 17 MOTHER FIRST MIDDLE MAIDEN Sl.1RNAME
<br />_ (Dec.) Henry Earl Korea I
<br />18 N/A`, 0FCFASFD EVER IN US ARMED F']RCFS° Korea 'II rBa INFORMANT NAME
<br />Yesrhxl lib rya, :)t yry 150 -1 1 -1957
<br />_ Carob
<br />19h NFORMANT MAn-INO AI)DPFSS ISTnEFT OR P. F n No CITY OR TOWN, STATE ZIPI
<br />Dec.) Helen Mae Fleming
<br />414 N. Cedar Street._
<br />Grand
<br />-- Island
<br />Nebraska 68801
<br />'::FMF.
<br />20 F .MHAI,MF.R 51(iNAiIIRFhIICFN,SF (r
<br />:7' i METHOD OF
<br />DISPOSITION : ?1�ATF
<br />121,. I'ERY OR CHLMn(UHY NAME ..
<br />�
<br />- -- I ` ,
<br />tlur�al
<br />Jul 25
<br />2001 IGrand Island City Cemetery
<br />YI.'�R(INER AL HOME NAME
<br />IS,gnalure and T tl I 0
<br />1 210 CFMFTERY OR CREMATORY
<br />LOCATION 11 rY OH TOWN ^STATI'
<br />Kleine Funeral Home
<br />El Cremation
<br />❑ Dpnaiip
<br />Grand Island, Nebraska
<br />27h FUNFRAI HOME ADDRESS ISTRFET OR R F D NO. CITY OR TOWN STATE. ZIP)
<br />3213 W. North Front Street, Grand Island, Nebraska
<br />23. IMMEDIATE. CAUSE ICNTER ONLY ONE CAIJSE PER (.INF. FOR ,,: �bl. AND Irl)
<br />PA t
<br />Ia1
<br />Heart Attack
<br />..._!)111. I U, . WEASA CUr�:;kuLItNC:Lx - -.
<br />(bl
<br />OUC. I "O. OR AS A CON'EdUIFNC17 . OF
<br />1cl
<br />U I HCH JIUNINUAN I LUNUI r IUN❑ UehGM0hS contributing tD the death out not reraled
<br />PART
<br />Interval berween en;r�.y,r "Ya.a�
<br />tinRmqwn
<br />Inge al between else( and death
<br />PART III IF FEMALE. WAS THFHF A AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST MONTHS' EXAMINER OR CORONER•'
<br />IAgs•, 10 ,41 YGS Na. ❑, Y.; L Nu Ves Na ❑
<br />76a 21 ',ATE OF INJURY (Mo. Day. ✓r.) 27c HOUR OF INJURY 2eij DFS�.:RIRF HOW INJURY OCCURRFD
<br />1`l1 Ar.r,,denl u Undete'm,ned M
<br />Su u Ue L� Pend ng '. 76e NJ UNY q i' WUHK 7fil PLA(E OF INJURY At ho lawn n1r 1 laclory 26g LOCATION STREET )P N F U NO (;I I V OR low" S (A I C
<br />J Hn•n Cde Inv�5l garCn y.5 Np
<br />❑ oRce bu,l0ing. etc (Pee, I
<br />7711 DA T OF DEATH 10, 0- Yr) _ �28a UAIL SIGNED (Mr, UJy Yr; 2Ht, IIMF OF UEAIH
<br />Z;
<br />27b DATE SIGNED (Mo. OR y 27c TIME OF DEATH
<br />M
<br />6 00 pw
<br />r 28C PRONOUNCED DEAD IM(, Day, y,) .8d PRONOUNCED DEAD (H( J
<br />E - July 2q, 2001 1.l : 0 0 pm__
<br />' {
<br />771 To rho best of y k' enq. ', rh nr.r. ,net at the I— Jalu
<br />d ul:. - I'd Due , the
<br />28p. on (ne bass of exa n at or e. t g Yon, n my op n en it
<br />') h 'rep' r +t
<br />Cau,t I,' ,toted
<br />1 I roe. date and Pldce a ,d
<br />J_ 'c the a '. ',C I`I slalod
<br />IS,gnalure and T tl I 0
<br />IS ).lure and T 11eI P
<br />29 UIU TOBACCO USE CON I RtL UTE TO THE DEATH?
<br />Jo.a HAS ORGAN OR I ISSUE
<br />UONA TION BEEN CONSIDERED?
<br />W C its
<br />E
<br />❑ 'E5 L_-] NO ® UNKNOWN
<br />❑
<br />YES K, NO
<br />❑ YES
<br />NO
<br />ll NAME AND ADUHCSS UT CCHnFIF.n !PHVSICIAN,CORUNCRSPHYSICIAN OH 'JUNIV Ai I()HNLVI - TvpeaPr '/
<br />Sgt E Edwards, GIPD, 131 S Locust, Grand
<br />32 RLI;ISTRAR //t
<br />Imo_.. _..__... ...- ---- --........ � �._ !./ r y _. .............
<br />Island, NE 68801
<br />l..h 7niF FILED BY REGISTRAR rMn. Da; r'
<br />JUL 3 0 2001
<br />
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