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<br />~ <br />"> <br /> <br />WHENJHIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 'eRVICIE' <br />'SYS1E'Af. IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD DN.-FJU_WltH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISTICS,ftECTiQN;;Wfm:;tHS <br />tHE LEGAL DEPOSITORY FOR VITAL RECORDSOM.Af. . .Ji;. .....~:~J~..._:;J. ;.'~.'.-- ':~"?'~~._.~'~.._'" .... <br /> <br />DA TE OF ISSUANCE JV....".'j7L~,;y_s. GO~~'Rt, <br />2/17/2004 200510965 AssISTMli4TAJ-ERErilsw.R:'i <br />LINCOLN, NEBRASKA HEAL TH AND HU~/'!!-R~~~~~~~STE{lff}j <br /> <br />STATE OF NEBRASKA- DEPARlMENT OF HEALTIl AND HUMAN sERvrC~nN'MlC~~suProR'J:" <br />VITAL STATISTICS ':";;'~';'".""'c' -:,",. , ""'-("j'4 <br />CERTIFICATE OF DEATH "--')2.:~~:::.'.:.0 <br />2. S~X 3. 'DAT~ OF DEATH IMont/!. Day. yo.,! <br /> <br />.,...- <br /> <br />-.;.)" <br /> <br />1. O~C~OENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />01007 <br /> <br />LAST <br /> <br />Debra <br /> <br />Ann <br /> <br />Happold <br /> <br /> <br />Female <br /> <br />UNDER 1 OA Y <br />5e. HOURS' MINS. <br /> <br /> <br />January 28, 2004 <br />6. DAT!; OF BIRTH iMonlll. Day. Y.") <br /> <br />4. CITY AND STATE OF BIRTH IIfno/1n U.S.A., name country} <br /> <br />5a, AGE - L.ast Birthday <br />IY".I 52 <br /> <br />September 16, 1951 <br /> <br />Kearney, Nebraska <br /> <br />7. SOCIAL SECURTIY NUMBER <br /> <br />507-66-1419 <br /> <br />OIe.IISpecilyl Whi t e <br /> <br /> <br />Hall <br /> <br /> <br />00 Inpallont <br />o ER Outpatient <br />o DOA <br /> <br />OTHER: 0 NU($lllg Home <br /> <br />o Residence <br /> <br />o DIner (SpeCilV! <br /> <br />Bb. FACILITY - Nomo <br /> <br />St. Francis Medical Center <br /> <br />(If not institIJtion. give slr8Bt afl" rwmbsr) <br /> <br />Be'. CITY. TOWN OR lOCATION OF DEATH <br /> <br />ad. INSIDE CITY liMITS <br /> <br />COUNTY OF DEATH <br /> <br />Grand Island <br /> <br />9a. RESIDENCE. STATE <br /> <br />9b. COUNTY. <br /> <br />Nebraska <br /> <br />STREET AND NUMBER Ilnclu~lng Zip Cod'! <br /> <br />10. <br /> <br />11. ANCESTRY (e.g" Italian. Mexican, German. etel <br />ISoocl1yj American <br /> <br />68801 <br /> <br />ge. INSIDE CITY LIMITS <br />yosf] No 0 <br /> <br />13. NAME OF SPOUSE (If wife. give maidtm name) <br /> <br />LAST <br /> <br />17. MOTHER <br /> <br />Robert C. Happold <br /> <br />15. !;DUCATION ,Speelly only hlghe.t grade completedl <br />Elementary Or Secondary 10-12) College /1-4 Or 5.1 <br />12 5+ <br />MIDDl" MAIDEN SURNAME <br /> <br />14a. USUAL OCCUPATION (Givs kind of wor/( dan~ during mos1 <br />of workin.9 fits. 811e'n if r81iredJ <br />Teacher <br /> <br />. 16. FATHER. NAME <br /> <br />FIRST <br /> <br />MIDD"E <br /> <br />Grand Island Schools <br /> <br />Edward <br /> <br /> <br />Darlene <br /> <br />Hoffman <br /> <br />18. WAS DECEASED EVER IN U.S. ARMED FORCgS7 <br />(Yes. no, or unk.j (II yes. gIve war and dates of ser'Vices) <br />No <br /> <br />19b. INFORMANT <br /> <br />MAILING ADDRESS <br /> <br />Robert C. Happold <br />(STREET OR RFD. NO.. CITY OR TOWN. STATE. ZIPI <br /> <br /> <br />Calvin Dr. <br /> <br />Grand Island, Nebraska 68801 <br />21 a. METHOD OF DISPOSITION 21 b. DATE <br /> <br />Apfel-Butler-Geddes DcromOlion o DonOl,on <br />22b. FUNERAL HOME ADDRESS !STREET OR RF.D. NO.. CITY OR TOWN. STAT!;_ ZIPI <br /> <br />~ Bur'ol 0 Removal Jan. 31, 2004 Grand Island Cemeter <br />21d. CEMETERY OR CREMATORY lOCATION CITY OR TOWN STATE <br /> <br />21 e. CEMETI:RY OR CREMA TORY NAME <br /> <br />Grand Island <br /> <br />NE. <br /> <br />1123 West Second, <br /> <br />Grand <br /> <br />68801 <br /> <br /> <br />Interval between onset and deatl1 <br /> <br />2- ,d <br /> <br />Intelv etween onset nnd death <br /> <br />DUE TO. OR AS A CONSEQUENCE OF: <br /> <br />lei <br />OTHER SIGNIFICANT CONDITIONS - Conditions cOntributing to the dSath bur not relaled <br />PART <br />" <br /> <br />I Interval Detween Onset and oeam <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAl <br />EXAMINER OR CORONER? <br /> <br />26a. <br /> <br /> <br />26b. DATE OF INJURy iMp.. Doy. Yr.j 26c. HOUR OF INJURY <br /> <br />o Accident 0 Undetermined <br />o Suicide 0 Pending .26e. <br />o Homicide <br /> <br />26g. lOCATION <br /> <br />STREET OR RF.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />27a. <br /> <br />280. DATE SIGNED (MP.. Day. Yr.j <br /> <br />26b. TIME OF DEATH <br /> <br />is'~ <br />l~,. <br />~~~ <br />J'!'E <br />.e!l <br /> <br />27b. <br /> <br />z~ <br />~:5;~ <br />J~g <br />;ilrt:,. <br />EQ.<...J <br />8"'~8 <br />llffiz <br />Q t5 5' <br />~:5';O <br />,-,0 <br /> <br />29d. PRONOUNCED DEAD iHoutJ <br /> <br />26c. PRONOUNCED DEAD (Me.. Day. Yr) <br /> <br />M <br /> <br />M <br /> <br />28e. On the baSis of 9)(amination and'or investigation, in my opinion death occurred OIl <br />the time, dale and place and due to the cause{sl st:ated_ <br /> <br />M <br /> <br />29. <br /> <br />31. <br /> <br />30.b WAS CONSENT GRANT!;D? <br />o YES <br /> <br />o <br /> <br />,Gordon J. <br /> <br />Custer, <br /> <br />Grand Island, NE. <br /> <br />" <br /> <br />i 3... REGISTRAR <br />I <br /> <br />68803 <br /> <br />32b. DATE FILED BY REGISTRAR (Me.. Day. V,! <br /> <br />"- <br /> <br />FEB-=- ;] 2004 <br /> <br />1.':;"' <br />