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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN fldph4i "
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD OP�LE -WTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS•SECTldk ---
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DA i�IL`' C:OOPEii
<br />��� 200505524
<br />ASSI�'AA1'[ SWO RE[sISTW :=
<br />LINCOLN, NEBRASKA HEALTH AND HiMOM AIVICES $YSTLw''
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIES MhLkNC%:- �PORT
<br />VITAL STATISTICS — _ 1091,40
<br />--
<br />..._..— __... __ .....— _. - -_,.. _. ...._.__. S1-X _ 1 J DATE OF )FAIN Mrvrfl Od, 1'errl
<br />CERTIFICATE H
<br />InF('FDFNI .NAME FIRST MIDDIF LAS1
<br />Ronald Carl Metcalf Male August 11, -2001 —
<br />"' "" Sa AOE Last Rlnhday UNDER 1 YEAH IJNUCR I DAY ti. DATE llF HIH T'H iMr Ih. Dav YHarl
<br />4, CITV AND STATE OF BIHI'Ii /Il nUl r�,USA name rr!unhvl
<br />IYrs Sb M()ti DAYS SC HOURS "INS August 30, 1939
<br />Sar ent Nebraska _ _ 61 J -- - --
<br />:.--- -
<br />r SO(:IAL SLCURTIV NUMBEn H., 1a1 A(:E OF DEATH
<br />HOSPITAL L � "I,—bent OIn[R ❑ Nursing Hnr.+c
<br />505 -42 -3709
<br />•�... —... ...._. .. Fn Ompahent HeS�denCe
<br />Hb. FA(:ILITY Name /Il nr,l - nsnlunnrr. give ,slree.+! anrf nrrnrfkll')
<br />1411 North Park Avenue - -
<br />- " "-- '- Hd. INSIDE CIYY LIMITS Hr` I'C)UNTY OF DEATH
<br />Be . CITY TOWN OR I OCATtCN OF DFAI II ....; .. Tyr '.
<br />rand Iaiand, Nebraska Yes' No all
<br />9a. RESIDENCE - STATE 9b COUNTY 9c UITV. TOWN On LOC:A flON _ 9d. STREET AND NUMBER :Inc rurhng Zp �rxit +J 9e INSIDE CITV 1 IMITS
<br />Nebraska Hall
<br />and Island 1411 N. Park Ave. 68803 Y-E N°❑
<br />10 WAGE Ie g.. Whne Hlack. American Indian 11. ANCESTRY le .y. Italian, Me +scan. Oerman. etcl 12. MARRIED n wIDpWED 17 NAME OF SPOUSE 111 w +lv' give maiden narnel
<br />.In' „.,,Iy., S -fyl NEVER L ,r DlvnricLU Tanice P1Ilk9tOl1
<br />White American _MARRILD ��
<br />[(Yt!s 'JSUAI UC CUPnTION (Give krrrei w1+r4 nn e dur p mr!s! 14b KIND OF BUSINESS INDUSTRY �A1tUN P ?„ N uy t7he5l g atl nplale e
<br />nl w) F g ll/P. eWn r /relirerlf Fleme' la y 0 S .r.o tery '0 121 College 11 a n' r-
<br />Mail Carrier Postal Service 12 - -. --
<br />FATHER NAME FIRST MIDDLE LAST 11 MOTHER FIRST MIDDIF MAIDEN SURNAME
<br />Carl L. Metcalf Rozella Huss
<br />— .. - . ._
<br />UEC CASFU IN I15 ARMED FOHCFS7�, NFORMANT Yes Nav 1957 -1 6 nP nr �nv<.I n1���wdr and nale�, I;I Serv,°6Q Janice...,.Me tcalf _ .... - - - .
<br />19b INFUHMANT MAICING ADUALSS IS RERT OR R D NO., CITY OR TOWN. STATE. ZIPI
<br />14 th Park Avenue Grand Island, Nebraska 68803
<br />.... ❑ ❑ , � CREMATORY NAME
<br />„ _.. .. CITY 20. LMEA SIONATU t' LUG— O 21a METH ODOFDISPOSITIDN 21b DATE 21C CFMFILHY
<br />H °rat R,,--, Au ust 1S 200 Westl.awn Mem. Park Cremator
<br />21d CEMETERYUHCREMATOHY LOCH I IUN UH TOWN STATE
<br />77a FUNERAL ME ME
<br />Grand Island, Nebraska
<br />X Cremal�Pn
<br />Livingston- Sondermann F.H. _. -.- -
<br />?2h FUNERAL HOME ADDRESS ISMEET OR R.F D NO CITY OR TOWN. STATE. ZIP)
<br />6.01 North Webb Road Grand Island, Nebraska 68803 -
<br />... Interval between Onset dnn ream
<br />?g IM ME DIME CAUSE IENTEn ONLY ONE CAUSE PFR LINE FOR Tai 161. AND I :lj
<br />PART vc F—�
<br />X, lal { I 1 1L f Inlerval beMeen onsel and dealn
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />M. ��= ---ELI � Tt'�� c_ (? � �� ��t'�E C.+°� � �R- -> . �► � c,,,,�„�.,_,a,...�
<br />Y- (h) Interval between onset and neam
<br />(C) _ .... ..�
<br />OTHER SIGNIFICANT COND IC) Conditions cmmnbuting to the death hul not related PART III IF FEMALF WAS THERE A
<br />�11 AUTOPS Y 25 [XAC EORFCORUD[q F.IEDICAL
<br />PART PREGNANCY IN THE AST MONTHB(Ages IOS41 YP.s No s �NO Ve;�.._ No
<br />2fi1 DAI IL OF INJU - - -
<br />JFia r RY /Mp. Day. YrJ 2GC HOUR OF INJURY 2F.n. DESCRIBE HOW IN,IIIHY OCCIJRHED
<br />Acc,dent L I Undetermined M
<br />SuiG�de �J' PenUu,g 26e IN.ILIHV AT WORK 28f oXAe DOFF INgJp HY 'lS CilyJ tarm, mreel.IaGOry tog ICICAIION STREEI'C)n nFU NO. CITY OR TOWN SIAf[
<br />nHOMICIde Investigation Yes ❑ No
<br />— -�- 2tln DATE SIGNED /Mr! Oar Yr I 28h I IME OF OF.AT11
<br />27. DATE OF DEATH /Mu. Day YrJ
<br />X Q4 Iby ! a w - M
<br />9 ?7h DATE SIGN L /Mp fDay. rr r 27c. TIME OF DEATH �r $ r u 2Hc PRONOUNCED DEAD lMn •Day. Yr 1 28d. PRONOl1NCEU OF.AU (l+nlrrr
<br />rU L. A CVO .. .. f M u.. .. —..._. M
<br />�-A
<br />7 Tom esl of my knnwledy+. tleaU, uOLUrrer1 a1 the time. dart' and Plar.E, and nu, Io InC ° �' j 28eOn Ine basis of e><amination and or nvest galon n my opinion death occurred at
<br />causehl stales. n ” the time, dale and place and due to me causels1 stated.
<br />ISI naW .and ante ► / k�', ISI nature and TiUel ►•,,, .. - --
<br />2g DID TOBACCO USF CONTRIBUTE T(�THE DE H' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'! 306 WAS CONSENT GRANTED '>
<br />v/ YES VF.B
<br />YES ❑ NO ❑ UNKNOWN 7` -
<br />31 NAME AND ADDRESS OF CERTIFIER ( PHYSICIAN. CUHUNER'S PHYSICIAN OR COUNTY ATT09NEYI /TYPe I "Intl .7 2116 West Faid ley Ave •
<br />_rand 1,5land.-J�L 688.03
<br />- -- -- — :126 rgA IT FILED RY LIFCISTRAH (Mn. Day. YrJ
<br />32.a Hk I'I TRAH
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