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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA./!!}iERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINALii~CORD DynE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA[~tl(J5SECTJON/wiiiCH IS
<br />
<br />::::::;::::C:TORY FOR WTAL RECOROS.,f~M,I_~~,
<br />U.. AV 1 .8 2006 "1~"'7itANL-'EYS/CP(jP$
<br />"''''I 20060543 6 AS~ls'7'A-!,T_-STATE REgiSTRAR
<br />LINCOLN, NEBRASKA . HEAli{H AND'Hur.tAIY $ERV/~ES
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND-SUP PO .
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />5488
<br />
<br />1. DECEDENT'S-NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Sulfix)
<br />
<br />2. SEX
<br />
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />Ma
<br />
<br />6. DAn, OF BIRTH (Mo" Day, Yr,)
<br />
<br />
<br />Harrv Clvmo
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />~t..~Th~r
<br />Sa, AGE-Lasl Birthday
<br />(Yrs,)
<br />
<br />80
<br />
<br />5b. UNDER 1 YEAR
<br />
<br />-- ~~S_-_I~ DAY'S"
<br />
<br />May 8, 1926
<br />
<br />8a. PLACE OF DEATH
<br />
<br />506-22-6213
<br />
<br />1:i.Q.S.!'JI[>J:
<br />
<br />~ Inpatient
<br />
<br />Q1I:Ii:B: 0 Nursing Home/LTC 0 Hospice Facilily
<br />
<br />FACILITY-NAME (If not Institution, give street and number)
<br />
<br />o ER/Outpatienl
<br />
<br />o Decadont!s Home
<br />
<br />St. Francis Medical Center
<br />
<br />0=
<br />
<br />o other (Specity)
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />68803
<br />
<br />._"~,--~-,
<br />8d, COUNTY OF DEATH
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />2707 August: ~~};eet:
<br />10a. MARITAL STATUS AT TIME OF DEATH };l Married U Never Married
<br />
<br />Lb. COUNTY
<br />-~_?-p
<br />
<br />Grand Island
<br />
<br />. :0 APT.NO-r~~~~~~
<br />
<br />lOb, NAME OF SPOUSE (First, Middlo, Lasl, Suffix) II wile, givo maiden name.
<br />
<br />
<br />Hall
<br />
<br />.......---.1.--... ..... .........- ---.-
<br />9g. INSIDE CITY LIMITS
<br />:Rl YES 0 NO
<br />
<br />o Married, but separaled 0 Widowod 0 Divorced 0 Unknown
<br />
<br />Patricia Parsons
<br />
<br />11. FATHER'S-NAME (First,
<br />George
<br />
<br />Middle,
<br />
<br />Last, Sulllx)
<br />Stalker
<br />
<br />12, MOTHER'S-NAME (Flrsl,
<br />Jessie
<br />
<br />Middle,
<br />
<br />Melden Surname)
<br />Hayes
<br />
<br />13, EVER IN U,S. ARMED FORCES? Givo dafes 01 service ilyes. t4a.INFORMANT-NAME
<br />Yes 7/1944 7/1946 .
<br />(Yo~,.~?:?r_~._. Patric_:!'?Stalker
<br />15. METHOD OF DISPOSITION 16a, EMBALMER-SIGNATURE
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />o Burial 0 Donation
<br />
<br />.N.Qt embalmed
<br />lBd, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />Wife
<br />lBc. DATE (Mo., Day, Yr.)
<br />May___15. 2006
<br />STATE
<br />
<br />1 Bb, LICENSE NO,
<br />
<br />Illi Cremalion 0 Enlombment
<br />
<br />U Removal 0 Other (Spoclly)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a, FUNERAL HDME NAME AND MAiliNG ADDRESS (StrOOI, CilY orTown, Slate)
<br />A fel Funeral Home
<br />
<br />
<br />18. PART l. Enler the ~t~,--disea.ses, injuries, or complicalionsnthal direclly caused the death. DO NOT enter terminal events such as cardiac a.rrest,
<br />respiratory arrest, or ventricular fibrillation without showing the ellology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines il necessary.
<br />
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition ,esultlng
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) .po.~\j m_o_A.. \ ~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />
<br />on~~~~ ~.-------
<br />
<br />Sequentially IIsl conditions, if
<br />any, leading to the caUl!i1:! IIsled
<br />on line a,
<br />Enler Ihe UNDERLYING CAUSE
<br />(dIsease or injury that Initialed
<br />Ih. ov.nls resulting In deeth)
<br />LAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Onset to death
<br />
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS. Conditions conlributlng 10 Ihe dealh bul not resulling In Ihe underlying cause glvon In PART I.
<br />
<br />c: ':L (' C, f'\.\,)__f\I':\.~_. L ..) l\
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES -1;0
<br />
<br />20. IF FEMALE:
<br />o Nol prognenl wlihln pasl year
<br />U Pregnant allime 01 dealh
<br />
<br />21 a, MANNER OF DE
<br />~alural 0 Homicide
<br />
<br />o AccidenlU Pending Invesllgation
<br />
<br />21 b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o YES
<br />
<br />~O
<br />
<br />o Nol pregnant, bul pregnant within 42 days 01 death
<br />o Nol pregnanl, bul p,egnanl43 days to 1 yea' belore doafh
<br />U Unknown if pregnant within Iho past year
<br />22a DATE OFiNJURY-IMO, Day, Yr.)- J 22b, TIME-OF INJUR:
<br />
<br />-:;2ri:INJURY AT'WORK? - ]22. DESCRIBE HOW INJURY OCCURRED
<br />o YES 0 NO
<br />---. - -------
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />U Suicide 0 Could not be determinod
<br />
<br />U Pedestrlen
<br />o Other (Specily)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE)'F DEATH?
<br />
<br />o YES ~
<br />
<br />22c. PLACE OF INJURY-AI home, farm, street, laclory, oflice building, conslructlon site, elc. (Speclly)
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />230, DATE OF DEATH IMo" Day, yr.)
<br />OS" - \ ~- ~O() Ie
<br />230. TI E \;Erb m
<br />
<br />. best of my knowladge, death occurred at the time, date and place
<br />
<br />~~o~~atGu~~~\\ 1- ^" 0
<br />
<br />24a. DATE SIGNED (MO., Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>.~ ~
<br />",!;l~
<br />1l"'0
<br />HI:
<br />Q.D.~~
<br />~ffi~~
<br />"Z~
<br />"'00
<br />~rr.U
<br />85
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On Ihe basis of examInation and/or investigation, In my opinion death occurred at
<br />lhe tIme, date and place and dUB 10 the cause(s) slated. (Signature and Title) "
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />----.!:!....~~__~_..o PROBABLY 0 UNK~Ol'm U YES NO Nol~PP!'.r:ablo if 2Ba Is NO 0 YE NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNT ATTORNEY) (Type or Print)
<br />John J. Cannella M.D. 729 North Custer Grand Island. Nebraska 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />MAY 1 7 2006
<br />
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