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<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN.SERVlCES
<br />SYSTEM, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECosiiiJii:FfLf-.wrrH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/~TiOij.l"HtPfflS
<br />
<br />
<br />:::EJL:;'[:;;:OOR1Y FOR .,TAL RECORDa ~4'O~\j
<br />UI 'u --. '-.' ~. ~_ _.' ___'Co
<br />ASSISfANT-$fA'rE kEGtstRAl! ;,
<br />LINCOLN, NEBRASKA HEALTH AND H~R st=FMCES_l!-rstElrl.~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE$CE~_F~R'f\ND SUPfflRT
<br />CERTI~~~S;~~~~EATH '"O___o-~- . .:--._'-~-::tJ 1
<br />I, SEX ' -
<br />I
<br />
<br />07809
<br />
<br />! I Dr(:~~i.)f..N'
<br />
<br />NAMl-
<br />
<br />I=IH~~ I
<br />
<br />..-.'----MI-C;'l)lj~
<br />
<br />LAS!
<br />
<br />Male
<br />
<br />
<br />/Mor)ll~ Da~' 'r"e,~r,1
<br />
<br />f4-~CITY-AN-6-SiA~~:::~~: 11I';oi"l;'iXS4"~';',;counl'y! _, J
<br />
<br />Marr
<br />
<br />July 10,2001
<br />
<br />Scottsbluff, Nebraska
<br />
<br />"'--~..A(;t:
<br />~.--._"IY(".I.
<br />
<br />Las! BI(lMay
<br />
<br />UNDER 1 YEAn
<br />
<br />72
<br />
<br />!"",b MOS
<br />
<br />l)^Y~.;
<br />
<br />UNDER 1 DAY
<br />:,c-;lOu"A's. .
<br />
<br />DA Tf OF BlnTH /Month nav \/r-?ar)
<br />
<br />May 09, 1929
<br />
<br />7"-SOCIt\L SCC-URT'iy."NL/MO"[R
<br />506-20-2423
<br />
<br />80 F AGiliTY. Ni'lme
<br />
<br />(If no! tnSfitVlion, give .r;;lr~p.1 and rwmWr)
<br />
<br />8. rLACE OF DEATH
<br /> f lUSPI! Al [] Irl~I,~IIOr"'lt OTH[H 0 Nur:';IIllj I ((Jnl\'
<br /> 0 CH Oulpallent KJ AOsldoncc
<br /> D DO^ 0 O!Mr (5/-)/.J(IIV;
<br />
<br />
<br />312 North First Street
<br />
<br />g~ .'.Rt~';ID!::.NCE:. - S TAl E:
<br />
<br />9b COUNTY -
<br />
<br />. 8d :e:'OSJTY ~:MID r~:~~NIV(l>OEATH
<br />
<br />. _ _,~___,_,__,,_.;:._..L.
<br />
<br />l:~~'~i;~:;IHLOC^!lON ~dl;T~:;~~N~:;~t;:;;:':~;~_ I g" ~:':IDg]TYN~'Mo
<br />
<br />"."a',Mc",ca',Gelman.eICI '2U MARRIED 0 WIDowED 1" NAMEOFSPOUoe II/w"e y"",,,a,,'c" ",,,,,'!
<br />
<br />o ~~~~~bQ__D DlvoncF~_.L~!!tL~ilk ___
<br />14b KIND OF BUSINES5 IN[)U51RY 15 [{)UCA lION r$pl:!Clly only !~lghe5t g~M€'~.~~,~!.~.t~:5jl
<br />Owner/Operator Ele,,!ry Or SeCOM<lIY 10 1.?1 Collp.qp. :1 ,:\ 0' ~!' I
<br />
<br />8e, (IT"y', -r6WN OR LOC^TION orDtA-TH.
<br />
<br />Doniphan
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />10 r-:lACE. (C,g,,'wtiiie~BT.ick~~e'r~ca~.ln'd','a~'~T 11 ANCFSTRY I~,q
<br />""hint"" ..xsrn'~1ica n
<br />
<br />
<br />~,-~.~,,,.~._-~._'--"'_...
<br />1'\ri ~J~)LJAL OCCUPAllON (GIVe kind of wOfl< aono during mosl
<br />T~uOCke'P. even if retired!
<br />
<br />LAST
<br />
<br />17 M-(:)rH'ER
<br />
<br />FIRST
<br />
<br />MI['(lL-r-------'
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Clinton
<br />
<br />J
<br />
<br />Marr, Sr.
<br />
<br />Gertie
<br />
<br />A
<br />
<br />Johnson
<br />
<br />MAILING AD()R~S$
<br />
<br />I j-9ii INFORMANT. NAM[
<br />!
<br />i. Betty Marr
<br />
<br />(STREET OR R F D NO. CITY O~ 'fawN, STATE ZIP'I
<br />
<br />312 North 1st Street, Doniphan, Nebraska 68832
<br />
<br />'20 EMBALMER - SIGNATURE & lICE~~E NO
<br />
<br />~1!1/~ '111~t.( W:J L_
<br />
<br />2201, FUNERAL HOME NAME=
<br />Higby Mortuary
<br />
<br />1129
<br />
<br />,Ia METHOOOF OISPOSITI(JN 121'. DATE 'or. 'G.'~~~a_'_-,M,n._E~EAI:~:~~M~~;; ~_A.e,M~"e..,_ter;------
<br />tJ Bu"al 0 Rem'''.' I 07/13/2001 _.1~
<br />21 d CEMETERY OR CREMA TORY LOCA liON ClTv OR TOWN S 1 A r [
<br />o C"maMn 0 OonJW Grand Island, Nebraska
<br />
<br />220~F\j'N'ERAl HOME ADDRESS (STREET OR R.F.D. NO. ell Y OR TOWN 3T A n=, ZIPI
<br />P.O. Box 204 Aurora, NE, 68818-0204
<br />
<br />
<br />(ENTER' 6Nl. y' ONF CAtJSE PE:.H L1N( r6~-
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<br />Ir"\ter ell bet.....een onse! ,~nrj (1P.dt\'
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<br />11)1, AND Icll
<br />
<br />'"
<br />nlJF TO, OR AS A CONSf:::OUE:.NCE:. or
<br />
<br />
<br />-'1~T::~'~NIFICANT 'E6"DiiiO"S - Cood;"on. contributing '0 the de.'" I>ul nol ,01alM
<br />PAHI
<br />"
<br />,
<br />1-------...
<br />I ?O,' l26b DATE OF INJURY (Mo
<br />I, DO ",,,,,,,,,,,, 01 ~,__I UOdcwm,nM I
<br />SlJIr.>rlp. fJef1d'r"lQ [26(' INJUHY AT WORK
<br />o Homicide Ifwestlga1ion Yes 0 No
<br />
<br />,'-
<br />Inle~v.11 r!etwp.f!n onsf-ll arid IJ,-~,~TIl
<br />
<br />,.
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<br />l~ ,~~__.........,'~,.,
<br />
<br />Ii T~'
<br />
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<br />
<br />.,1.. "_..._.....
<br />15f ~k,~~:5uS~IA~J~~Y "rt;;g,~r farm, ';lrf!~t 1i-lt:l(Jrv
<br />
<br />Oav y;j--FHOUR OF INJURY"-
<br />I
<br />J.
<br />
<br />PART'-i.il"l~ f-!:MALE. WAS THERE A I ~';l-' AU.T-OPSY
<br />PHe.'.(.-iN.ANCY IN THE PAST 3 MO.N.THSbJ" .
<br />
<br />(~':J.~~_~!)-:..,..ji Yes n _~.?_ ,{~!~; n No
<br />! ?f.rd DeSCRIBE HOW INJuny OCClJHHED
<br />
<br />.._----,..
<br />25 WAS CASF R,eEHHW to MEDICAL
<br />f:XAMINI::H OH COHONUP
<br />
<br />.Y_f~"" n r-lo [Zt-.
<br />
<br />M
<br />
<br />! 209 LOCh TION
<br />
<br />'~ r~[:T :J~ r~ r D NO
<br />
<br />CITY OH faWN ST^TE
<br />
<br />. -l28;'~iIMl (,. "f~---~--
<br />
<br />27a DATE OF- DEATH (flAo Lh)y. Yr.J
<br />
<br />28<1 DA TL SIGNeD (Mo na~. '('r!
<br />
<br />
<br />,;; I _~ JU,l_~_2.9 ' 200 1 ., ,.. "!
<br />
<br />I ~ , t M" ~"'o ,~ ~, '" ""eo' OW" i H, ,. '~","""",^O ", 0",'" - ,"'"o"",,,"'^" "M,"
<br />
<br />5~"5 July 13,2001 A. M ~~~" m_-,_'___n_._"!.....-
<br />
<br />~ ~ 127d-.T~~h~beslol my ~r"'IO~ldd althe IlrllU, .~ l' ~ ;?8e On thp. bi::lslsol eX3rr1H1ClIIOrl JM or Investigation, in myopinlClrl dP.:.1U\ 'Jc(;urrej ,~t
<br />-.... cn\JSf-!ISI5t3Ied \,/ \ ,./ 1.-. ..~~':.~ ..~ -... lhe tllnc dale and place anrl ri(JP. to thE:! causers) stated
<br />
<br />__,,__...L...I.?,'.g.0~~.~.nd Title) III- .__ I (SlgnClture and f'lle) iii- ..,_,_____.,..._.,'.
<br />I '" DID 10. 8ACCO uS!::. CONTR..'..BUTE TO THE E:.Al '1 R TISSuF [)(.lNA liON BEEN CONSIDERED? I 30 b WAS CONSENT GRANTI::D!
<br />
<br />[J YeS [::r;:; 0, UN 0 YFS [~o- 1 0 yes r-2LNO
<br />i
<br />:.), NAMF.-ANO-AO"ORF'SS 0':: CEHli'FIEA IPfiYSICIAN, CORONER'S PHYSICIAN OR COUNTy ATTORNEY ,""- I';'Y~;-Or' Prllll'
<br />
<br />Ryan Crouch, M.D. 800 Alpha street
<br />
<br />Grand Island, NE
<br />
<br />68803
<br />
<br />
<br />I ]2b OA'TE FIL[D By REGISTRAR (Mo DnV Yr i
<br />
<br />, JUL 1 8 2001
<br />
<br />)?~ q[GISTRAR
<br />
<br />_____1....
<br />
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