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<br />. WHlN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA $oTA TE DEP.JiR"i:MENr-bflili!iiT.H, <br />" CERTIFIES THE BELOW TO BE A TRUE COpy OF AN ORIGINAL RECORD OIY fJl$~W/TR"rHE-jf.AiE, <br />DEPARTMENT OF HEALTH, BUREAU OF V"AL STATISTICS, WHICH IS THE-tEeM DEPOS1Tb1iY--iQIj~\ <br /> <br /> <br />:;;:'::~CE 200511464 '~~- <br /> <br />JAN 1 5 1997 ASSISTANT~TA7'E"MG1~TRAjf <br />.UNCOJ.tL.NEBRASKAf!E.B.RA~KA. DEPA!ffM~Nr pF#E~TH <br />STATE OF NEBRASKA - DEPARTMENT OF HEALT-iFc."c=___='"'-=-" <br />BUREAU OF VITAL STATISTICS--:':";o,-- <br />CERTIFICATE OF DEATH <br /> <br />FIRST <br /> <br />LAST <br /> <br /> <br />\. DECEDENT - NAME <br /> <br />MIDDLE <br /> <br />2 SEX <br /> <br />(Mon"'. Day. Y""'I <br /> <br />Glenn Burde <br />4. CITY AND STATE OF BIRTH flfnolr. U.S,A.. nams country) <br /> <br /> <br />UNDER 1 YEAR <br />5b. MOS. DAYS <br /> June 22 1910 <br />PLACE OF DEATH <br />HOSPITAL' D lnpallent OTHER. IKJ Nursing Home <br /> D ER Outpatient D ReSidence <br /> D DOA D Othe, {Speedyl <br /> <br />Cairo Nebraska <br />: 7. SOCIAL SECURTIY NUMBER <br />. <br />1 506-09-4567 <br />~ Ob FACILITY - NOme (1/""'.,.-, g1~._t.ndn_) <br /> <br />. . <br />11 . Park Pla<:e.J:Ilurs1n Center <br />oc. .CITY TOWN OR LOCATION OF DEATH <br /> <br /> <br />Grand Island <br />90. RESIDENCE - STATE <br /> <br />Hall <br />STREET AND NUMBER (1n<:IIXI;ng Zw c_) <br /> <br />ge. INSIDE CITY LIMITS <br /> <br />NoD <br /> <br />.. <br />-i 16. FATHER - NAME <br />'41 <br />.. <br />11 18. WAS DECEASED EVER IN U.S. ARMED FORCES' <br />fYes. no, or I.mk.} II' yes. give war an:! date5 of serviCes) <br />Yes 1942 - 1945 WWII Anna Belle Whitehead <br />19b. INFORMANT MAILING ADDRESS (STREET OR RFD. NO. CITY OR TOWN. STATE. ZIPI <br /> <br />FIRST <br /> <br />Self-Em 10 ed <br />LAST \7 MOTHER <br /> <br />Anna Belle Crumrine <br />15. EOUCATION ISpeclfy only "'91>0" ,lido eomplelod) <br />8emenrary or Secondary /0.121 Couege /1-4 Of S"I <br />2 Years <br />MAIOEN SURNAME <br /> <br />MIDDLE <br /> <br />14(1. <br /> <br />White <br />USUAL OCCUPATION (GivokiMoI__/Iuffllgmolt <br />of working life. even if rehtet:1J <br />Mechanic <br /> <br />'J <br /> <br />Lloyd <br /> <br />NMI <br /> <br />Whitehead <br /> <br />Frances <br /> <br />NMI <br /> <br />Reed <br /> <br />198. INFORMANT - NAME <br /> <br />818 West <br /> <br />14th Street, Grand Island, Nebraska <br />210. METHOD OF DISPOSITION 21b. DATE <br />/ D9 .. <br /> <br />68801 <br /> <br /> <br />:J. <br /> <br />D Bunal <br /> <br />D Removal <br /> <br /> <br />21e. CEMETERY OR CREMATORY - NAME <br /> <br />21d. <br /> <br />NE Crematio <br />CITY OR TOWN <br /> <br />service <br />STATE <br /> <br />Kleine Funeral Home <br />22b FUNERAL HOME ADDRESS ISTREET OR RF,O, NO.. CITY OR TOWN. STATE. ZIP) <br /> <br />[XI Crerr'lali&)n D Donation <br /> <br />Gibbon <br /> <br />Nebraska <br /> <br />'I <br />, <br /> <br /> <br /> <br />, Interval between onset aM death <br />I <br />I <br />I <br />I Interval b&twMn onset and deall'l <br />I <br />I <br />I <br />1 InMr~al between onset and death <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEOICAL <br />EXAMINER OR CORONER' <br /> <br />.I <br />41 <br />.I <br /> <br />Ibl <br />DUE TO, OR AS A CONSE~UENCE OF: <br /> <br />lei <br />PART OTHER SIGNIFICANT CONDITIONS. Gondijlon. eorWit>u1ing to lno d...h btA not ,.1010<1 <br /> <br />" <br /> <br />;u>- <br />~ !~~ <br />-.i~f <br />IJ <br />.J <br /> <br /> <br />263. <br />0 Accident 0 Undetermined <br />0 Suicide 0 Pencling <br />0 Homll:;ic:le InveS1igation <br /> 2720. <br /> <br />28b. DATE OF INJURY (Mo.. Day. Yr-J 26e HOuR OF INJURY <br /> <br />:!tie. INJURY AT WORK <br />Y.. D NO D <br /> <br />269. LOCATION <br /> <br />STREET OR RF.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />203. DATE SIGNED {Mo.. Day. Y',I <br /> <br />28~. TIME OF DEATH <br /> <br />~~~ <br />I;I~ <br />~h <br /> <br />M <br /> <br />28c PRONOUNCED DEAD (Mo.. Day., Yrl <br /> <br />2M PRONOUNCEO OEAD (Houri <br /> <br />M <br /> <br />M <br /> <br />288. On me basis of e)l;aminatlOn and/or investigation. in my opinton death occurred al <br />the lime. dale and place and due to the cause('!';) $taled. <br /> <br />DYES <br /> <br />3O.b WAS CONSENT GRANTED? <br />DYES <br /> <br />~~ <br /> <br />J1. NAME AND ADDRESS OF CERTIFIER (pHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (TYPO 01' Print) <br /> <br />Gordon J. Hrnicek, <br />320. REGISTRAR <br /> <br /> <br /> <br />1997 <br />