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Rev. 11/97 d c O O U a C 0 O U O N C E dd x d I� Z W E. o Lu U Lu 0 L CL O a Lu G (n 7 Q Z LL c•O STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS 200309862 . CERTIFICATE OF DEATH t. DECEDENT -NAME FIRST MIDOLE LAST 2. SEX 3. DATE OF DEATH /A4o W7. ay. Yawl Leonard Ra mond McCarty Male July 15, 2001 4. CITY AND STATE OF BIRTH /M rid h USA. mama Cawley/ SL AGE -Lame Btrd.y I UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /A4w*t ay. Ywl 50. MOS DAYS Se. HDQRS MWS. feral Merna, Nebraska 83 ' November 23 1917 SOCIAL SECURTIY NUMBER Ba PLACE OF DEATH 5 0 8 - 0 3 - 7 313 HEAL X 1i &wV OTHER: Nw" Horn, 17. . FACILITY - Hams /r-d ruYaaidrl plVl Mee and ndntbw) ER OLVated Resies. St. Francis Medical - Center DOA ❑ DowIswayl . CITY. TOWN OR LOCATION OF DEATH Md. INSIDE CRY UMITS N. COUNTY OF DEATH Grand Island Yes ® N0 ❑ Hall Bi RESIDENCE . STATE 91). COUNTY BF CRY. TOWN OR LOCATION TREET AND NUMBER IftWi g Ip Cods) 9s. INSIDE CITY LIMITS Nebraska Hall Grand Island ;2`0 E. 10th St.68801 Yes IN Hd❑ 10. RACE - la0. Wllte. Black. American Indian. 11. ANCESTRY N -0. Mahn• AAesiCanl Germatl etcl 11. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /Y -* 9r•+muds- nano/ W-1 Isoacm White (Specoyl I American NEVER DIVORCED Catherine S t e n k a 14a. USUALOCCUPATION /Giw Aindo(wradpudknVmdp 140. KIND OF BUSINESS INDUSTRY 115. EDUCATION (SWAyonty "grade co- MteUd) EWorw llry or S000ndwy 10.121 College it -4 or 5.1 of wq I r p Ak ~ inidred) Master Plumber plumbin I 12 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Michael McCarti Irene Dale • tt. WAS DECEASED EVER IN U.S. ARMED FORCES? WWI I 19a INFORMANT •NAME free. p unkl IM yea piYS rat and tlaW d a«vldaal es Dec.12 1942 -Jan.9 194 s Catherine McCarty 180. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO_ CRY OR TOWN. STATE n% 520 East 10tIL St. Grand Island Nebraska 68801 20. WER •SIGN RE ENS 21 a. METHOD OF DISPOSITION 210. DATE 21 c. CEMETERY OR CREMATORY - NAME Q ® e„+.I E] Rerrlovat J u ly 19.,' 2001 1 Dale Valley Cemetery a FUNERAL ME 21d CEMETERY OR CREMATORY LOCATION CRY OR TOM STATE ❑oanYon ❑D.. Custer County, Nebraska All Faiths Funeral Home 77n FI INFRAI Hf1MF AnMFSS ISTRFFT OR RFD. NO_ CITY OR TOWN. STATE ZIP( 2929 S Locust St Grand Island Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LB4E FOR 14 9* AND (CI) I do *I between ages and dean, PART /w/ r 4 14+ �1� / �6 I I bet «eel DUE TO. OR AS A CONSEQUENCE OF taatvat or" and deem D I (bl AN6U ntio N / A ZAA' DUE TO. OR AS A CONSEQUENCE OF: - I Irlerval beftew on& and dean I 1 Icl OTHER SIGNIFICANT CONDITIONS - Conditions Catetbuq to nn death but not rW W PART W IF FEMALE WAS THERE A 21. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART C /� PREGNANCY W THE PAST 3 MONTHS? EXAMINER OR CORONER' e V /y� & G4� i L.. /{/ 1 1 A) c/ V15" M (Apes 10.54) Yes Nd In- Nd Y« NO r7 2%. DATE OF INJURY IMO(. ay. YX4 260. HOUR OF INJURY MIL DESCRIBE HOW PUURY OCCURRED Accdwt Undatermned M ❑ Sonde ❑ Pending 26s. INJURY AT WORK 264 PLACE DF .URY /N I - farm, steel locby 26p. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ❑ Hdnw de W.090dn Yes ❑ No ❑ aloe blalanp sOSCAY/ 27a DATE OF DEATH /Aad. ay. Yr.) 211a DATE SIGNED /M0. ay. Yr.) 26b, TIME OF DEATH a July 15 2001 a M 27b. DATE SIGNED IMa. ay. YrJ 27c. TIME OF DEATH 28c. PRONOUNCED DEAD /Md. ay. n) 2Bd PRONOUNCED DEAD /mount <a 8 7-16-d 11 :27 M a M 27d. To the beet d my od:cor Ir and place and that to 914 20s. On to basis d ettwh neon and/or tNest gabon, in IN op not death occurred at cauws) waled. a INS Irne. data and dace and dw to Its deuemal sued r I - tore and Title and Twe 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? �y ❑ YES MCCL ❑ UNKNOWN El YES NO YES IXI NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) /7yp, or A" David Colan, M.D.,729 N. Custer Ave. Grand Island, Nebraska 68803 FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II NSC.................................................................................................................................................................I.......................... ............................... Work......................................_ .................................................................................................................................................................................. UC ................................................................................................................................................................................................ ............................... Reject....................................................................................................................................................................................... ............................... 0 ►Anted with scat Ink on MYCIed POOH I, Certify this is a true and Exact copy of the original. \ \ TMV........................... Census Tract No. .................. ...............................