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WHEN THIS COPY CARRIES THE RAISED' SEAL OF THE NEBRASKA STATE DEPARTNAI1!;
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON FEE 'STATV
<br />DEPARTMENT. OF HEALTH, BUREAU OF VITAL STATISTICS. WHICH IS TO LEO* 17, C1��dR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200602590
<br />_
<br />SEP 61995 ABS�sT= s>~AT�srsRR -
<br />LINCOLN, NEBRASKA NEBRASKA'DM40- �fEN*3DF.NEAETH - r
<br />STATE OF NEBRASKA — DEPARTMENT OF HE1A -
<br />BUREAU OF VITAL STATIS nC9
<br />CERTIFICATE OF DEATH
<br />94 W. Louise, Gran
<br />EM ER - SIGNATURE a ICENSE .
<br />r " Il I • 1 0 tY'
<br />Apfel - Butler- Geddes Fune
<br />M. FUNERAL HOME ADDRESS ISTREET
<br />1123 West Second Grand 1
<br />23 IMMEDIATE CAUSE �J
<br />PART
<br />I Ian �r
<br />DUE TO, OR AS A CONSEOILENCB OF
<br />ib,
<br />DUE TO, OR AS A CONSEOUENCE OF
<br />I , , vw"pXYsP <YK1-
<br />Ibraska 68801
<br />21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />Af43 ® Surlal [] Renuva; 08/30/1995 Westlawn Memorial Park Cemetery
<br />211. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />WI) ❑ c— El Donau- Grand Island, Nebraska
<br />R.F.D NO,. CITY OR
<br />68801 -5899
<br />ONLY ONE CAUSE PER LINE FOR fat. 161• AND (ell
<br />Imoval bellveen onset and death
<br />Wksl
<br />I
<br />Interval between Onset and death
<br />Interval between ousel and cealh
<br />I
<br />// IG A
<br />1z , r) ✓;' G
<br />1. DECEDENT. NAME FIRST MIDDLE LAST
<br />2 ai�,1s G .,
<br />.3,. DATE OF DEATH iMOmh pay. Year)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />Yes No
<br />Donald C.
<br />Cargill
<br />Mle
<br />August 27, 1995
<br />6. CITY AND STATE OF BIRTH bind ar U.S.A. flame CoLffory)
<br />M .
<br />50 . AGE - Last Birmy
<br />UNDER 1 YEAR -.
<br />'UNDER' 1 DAY
<br />8. DATE OF BIRTH /Mona/. pay Year/
<br />Sb. Mos. DAYS
<br />u. HOURS MINS
<br />Kearney, Nebraska
<br />fYrs l 62
<br />October 03, 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />27 August 1995sw
<br />8a. PLACE pF DEATH
<br />508 -32 -8262
<br />276 DATE SK+NED /W Day Yr'
<br />HOSPITAL ® I. OTHER ❑ N�rs ng Home
<br />- - --
<br />28C PRONOUNCED DEAD (MC pay, Yr.
<br />20d. PRONOUNCED DEAD /Hour)
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY, Name (a npl rrefift l , giw sirm add dumber)
<br />St. Francis Medical Center
<br />¢�
<br />r
<br />v
<br />❑ DOA ❑
<br />M
<br />27d To the h961 d my k wledge m occurred at the bme, late and place and due to the
<br />Capte151 stood,
<br />I e and Tide / .G �Yi'ifT Y
<br />28e. On vIe baeMS d axamnaaon and -a nvestigation, in my opinion death occurred at
<br />d1e tme, data IY1tl pace and dPe 10 the caused stated.
<br />S and Title
<br />Other iSpec,ry;
<br />Sc CITY. TOWN OR LOCATION OF DEATH
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED,
<br />Bd INSIDE CI �CjhJy,IX,f]E.pEpxu_.
<br />-.
<br />Grand is ant
<br />❑ YES N NO
<br />Yes ] ❑ Hall
<br />y EIJ��Ip
<br />n""� omas� erne fP" Fai ey'�"ve ;`�'" rankfTs`�ii4r, fli°'ie raska, 68803
<br />31 ].Jr
<br />No
<br />326 DATE FILED BY REGISTRAR (W... Day. Yr.)
<br />9a RESIDENCE -STATE
<br />9b COUNTY
<br />1 SEP 11995
<br />9c CITY, TOWN OR LOCATION
<br />Bd. STREET AND NUMBER iklcxgYg Zw CadeI
<br />9e INSIDE Cm' LIMITS
<br />Nebraska
<br />all
<br />Grand Island
<br />004 W. Louise, 68801
<br />Y� ❑
<br />10 RACE • le.g., Whft Black. American Wien
<br />11. ANCESTRY le .g.. Retain. Mexican, German, etc)
<br />RRIED
<br />❑ WI ED
<br />to NAME OF SPOUSE (n -de grw merden dprr al
<br />1�"I
<br />American
<br />VER
<br />M:N
<br />DIVOR CED
<br />Irene A. Kelsey
<br />141k USUAL OCCUPATION (Give katdd Ilok dole dM rWV mt$r
<br />1411 KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpecdy only highatIl graft COmpoted(
<br />dwnrkxlg ft awn if rehredl
<br />Owner / perator
<br />Trucking Company
<br />E or Secondary 10121 Caflllge a 5 -I
<br />It -4
<br />16 FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />George L.
<br />Cargill
<br />Lucille Tuma
<br />18. WAS DECEASED EVER IN U,S. ARMED FORCES?
<br />1901 INFORMANT - NAME
<br />(Yes fro. or unk.l In yes give war and data= Of servrdesl
<br />No
<br />I
<br />Irene A. Cargill
<br />94 W. Louise, Gran
<br />EM ER - SIGNATURE a ICENSE .
<br />r " Il I • 1 0 tY'
<br />Apfel - Butler- Geddes Fune
<br />M. FUNERAL HOME ADDRESS ISTREET
<br />1123 West Second Grand 1
<br />23 IMMEDIATE CAUSE �J
<br />PART
<br />I Ian �r
<br />DUE TO, OR AS A CONSEOILENCB OF
<br />ib,
<br />DUE TO, OR AS A CONSEOUENCE OF
<br />I , , vw"pXYsP <YK1-
<br />Ibraska 68801
<br />21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />Af43 ® Surlal [] Renuva; 08/30/1995 Westlawn Memorial Park Cemetery
<br />211. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />WI) ❑ c— El Donau- Grand Island, Nebraska
<br />R.F.D NO,. CITY OR
<br />68801 -5899
<br />ONLY ONE CAUSE PER LINE FOR fat. 161• AND (ell
<br />Imoval bellveen onset and death
<br />Wksl
<br />I
<br />Interval between Onset and death
<br />Interval between ousel and cealh
<br />I
<br />// IG A
<br />1z , r) ✓;' G
<br />or
<br />OTHER SIGNIFICANT CONDITIONS - Candlnons catrblaing 10 the death Ma not 1.1oild
<br />PART rr r
<br />II 1 {] max./ �. r 5 � � ,L'%C i1G�r5
<br />PART tit IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />)Ages 10 -54( Yes Na
<br />24 AUTOPSY
<br />Yes Np
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />Yes No
<br />26a
<br />2% DATE OF INJURY /Mp., Day, Yr./
<br />26c. HOUR OF INJURY 26d, DESCRIBE HOW INJURY OCCURRED
<br />Accldem ❑ Undelermmed
<br />M .
<br />❑ Sulelde ❑ Penang
<br />❑ HOMICAe Inw)sigabon
<br />26e. INJURY AT WORK
<br />Yes ❑ No 1-1
<br />26t, odi e E OFINJUUcRY - At tonne, farm, sneer. factory
<br />olfi 6011Mi BGwM')
<br />76g. LOCATION STREET OR R. F.0 NO. CITY OR TOWN STATE
<br />27a DATE OF DEATH /Aa.. Day. Yr.1
<br />2Ba. DATE SIGNED (Ad. Day Yo
<br />28b TIME OF DEATH
<br />27 August 1995sw
<br />T �+
<br />M
<br />276 DATE SK+NED /W Day Yr'
<br />27c TIME OF DEATH
<br />28C PRONOUNCED DEAD (MC pay, Yr.
<br />20d. PRONOUNCED DEAD /Hour)
<br />°
<br />28 Au t 1995
<br />12:59 M
<br />¢�
<br />r
<br />v
<br />M
<br />27d To the h961 d my k wledge m occurred at the bme, late and place and due to the
<br />Capte151 stood,
<br />I e and Tide / .G �Yi'ifT Y
<br />28e. On vIe baeMS d axamnaaon and -a nvestigation, in my opinion death occurred at
<br />d1e tme, data IY1tl pace and dPe 10 the caused stated.
<br />S and Title
<br />29 DID TyOBBA�CCO USE CONTRIBU TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED,
<br />30.b WAS CONSENT GRANTED')
<br />YES ❑ NO ❑ UNKNOWN
<br />/`l
<br />❑ YES N NO
<br />❑ YES IV NO
<br />///"""tYY�
<br />y EIJ��Ip
<br />n""� omas� erne fP" Fai ey'�"ve ;`�'" rankfTs`�ii4r, fli°'ie raska, 68803
<br />31 ].Jr
<br />32a REGISTRAR
<br />326 DATE FILED BY REGISTRAR (W... Day. Yr.)
<br />A*-
<br />1 SEP 11995
<br />or
<br />
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