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WHEN TMS COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND 19W& SERVICES <br />SYSTEM IT C8M ES THE BELOW TO SEA TRUE COPY OF THE ORIGI RIM - L `"I' H <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA - IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORD& z <br />DATE OF ISSUANCE <br />DEC 2 2002 200316218 <br />A�RSISTA�i`Str� <br />LINCOLN, NEBRASKA HEALTHAN&IMIJAM' <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN �7:qMSUPPORT <br />VITAL STATISTICS O <br />CF-RTTFICATE OF DEATH <br />12348 <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH iMonm Day. Year/ <br />Bernell Calvin Shum <br />Male <br />October 22, 2002 <br />4. CITY AND STATE OF BIRTH fit not in USA. name Country) <br />Sa. AGE - Last Birthday <br />EA <br />UNDER 1 YR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /MonOh. Day Yearl <br />Mos. I DAYS <br />Sc HOURS MINs. <br />Marysville, Kansas <br />(Y'S.) 76 5b. <br />July 1, 1926 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />514 -12 -9964 <br />HOSPITAL. 1K Inpatient OTHER_ El Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (tf not msfihAion, give street and number) <br />St. Francis Medical Center <br />❑ DOA ❑ Other/SpeCH' <br />6c. CITY. TOWN OR LUCA PION OF DEATH <br />8d INSIDE CITY LIMITS <br />Ile COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />9b COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /InUuding Zip Code/ <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1108 S. Greenwich 68801 <br />Yes ® N0 ❑ <br />10. RACE -(e.g., White. Black. American Indian <br />11. ANCESTRY fe g.. Italian. Mexican. German. etc) <br />12. ❑ MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE /it wde give maiden name) <br />etc .I ISoecdyl <br />White <br />(Specify) <br />American <br />1 <br />NEVER ORCED <br />DIVX <br />MRI <br />140. USUAL OCCUPATION /Give k/ndof work done during most lab <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed! <br />Elementarya Secondary 10 12) College 11 4 o 5 -I <br />12 5+ <br />of waking tile, even d reAntol <br />Lt. Police Officer <br />Grand Island Police Dept <br />16. FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Calvin Otto Shum F <br />Norma McFarland <br />118. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a INFORMANT -NAME <br />I, es� enWWI I6fe5 _giv7w)8/1t944aide56/3/1946 <br />James Shum <br />4 <br />19b. INFORMANT MAILING ADDRESS (STREET OR R F NO_ CITY OR TOWN. STATE. ZIP) <br />1720 Ryan Ct., E1 Dorado, KS 67042 <br />20. EMBALMER - SIGNfrUFW <br />& LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY. NAME <br />w{, /7k{it�'Wr2z7 <br />[Rfftmat ❑Removal <br />Oct. 25, 2002 Ft. <br />McPherson National <br />22a. FUNERAL HOME -NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel - Butler- Geddes <br />❑E« ❑ten.. <br />Maxwell, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( - <br />1123 West Second, Grand Island. NE 68801 <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR I Ib). AND (c)) ( Interval between onset and dean. <br />PART 1 r-11 I r� /� n /� I' (r 71 1 <br />/X)1!/ 1 ` 0 <br />l /l U I <br />/� /1 <br />(al l <br />DUE TO, OR AS A CONSEOUENCE OF I Interval between onset and Hearn <br />I <br />j <br />Ibl <br />DUE TO. OR AS A CONSEOUENCEOF: I Interval between onset and deatn <br />1 <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />111 IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS, <br />EXAMINER OR CORONER' <br />II <br />(Ages <br />10-541 Yes No <br />Yes No X <br />Yes n No <br />26a <br />26b. DATE OF INJURY (Mo.. Day Yc1 <br />26c HOUR OF INJURY <br />26d, DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Smclde Pending <br />26e. INJURY AT WORK <br />LUq1 hpr� . farm. street. facbry <br />261. o6ice bullFI ¢ <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes No F-1 <br />t(U ai'1 <br />etc SPA <br />27a. DAT DEATH (I Day, <br />28a. DATE SIGNED (Mo. Day. Yr) <br />28b. TIME OF DEATH - <br />) �/( <br />z ' <br />= <br />M <br />27b DATE SIGNED (W. Day Yr/ <br />27c. TIME OF D f^ <br />� �lv, <br />28c PRONOUNCED DEAD (MO.. Day. YrI <br />28d. PRONOUNCED DEAD (lour) <br />< <br />$ � <br />Oct. 22, 200 <br />�. M <br />E5 <br />M <br />° <br />28e. On the basis or investigation, in my opinion death occurred at <br />27d. To the bell W my k death occurred at the time, da piace due to <br />/ <br />~ <br />of examination and <br />causelsl stated. <br />the time. date ant dace and due to the cause(sl stated. <br />1S1 nature ant Title � <br />ISM nature ant Title ll� <br />DID TOGA <br />CO USE CONTRIBUTE TO THE DEA ? <br />ORGAN OR TISSUE DONATION BEEN CONSIDERED'( <br />30.b WAS CONSENT GRANTED? <br />129 <br />rTHAS <br />YES 1:1 NO OWN <br />❑ YES O <br />❑ YES ❑ NO <br />31 _ NAME A ADDRESS OF CERTIFIER PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEVI (Type or Pr tl <br />Andjela Drincic M.D. V.A. Medical Ce ter Grand 131and, F. 698011 <br />32a REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />OCT 3 0 2002 <br />