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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANOHUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAkjjEr;qiijifiN'J;:1kE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATJ~/c;-S$Ef!.T;li;)}Jj-~FllfH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. t ;,~,,;,~)'~l "ii2 -c~,
<br />
<br />DATE OF ISSUANCE ~Tf.!~~
<br />
<br />JUL 0 6 2006 200606 21 7 ASsisTANT STATE REGiSTRAR
<br />LINCOLN, NEBRASKA HEA~lH "1}":.HU",,~N.sER,!1f.:ES
<br />
<br />STAlE OF NEBRASKA- DEPAll1MENTOF HlW..1H AND HUMAN SEIlVJCES FiffAilcE ANDsUJitiOkt-:"
<br />CER~~~~EATH --. -..""03 14588
<br />
<br />. 1 DE"DENT. NAME
<br />
<br />FIRsr
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />~ :;EX
<br />
<br />13 OArEOfOEArH ,-.." V" V_I
<br />I December 7
<br />
<br />2003
<br />
<br />I Hal h
<br />
<br />I. em AND STATE 0' IlI~T'" '">lOt" USA -..c.JUII/1yl
<br />
<br />Male
<br />UNDER f OAV
<br />5< HOuRS _S
<br />
<br />Benjamin Collamore
<br />So. AGE. Last 80....,., UNDEfl f YEA~
<br />IY" I 51> MOS l),I,VS
<br />86
<br />
<br />ti OATF. Of 81RTt' ,_ 0., "_I
<br />
<br />Se tember 7,
<br />
<br />1917
<br />
<br />Harrison
<br />.. 7 SOCIAL SECUATIY ,..u~BER
<br />
<br />NE
<br />
<br />IlII PLACE Of DEATH
<br />~T~ rn.-
<br />o ER o..-w
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<br />-D-QOA
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<br />01 ><ER
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<br />O~UI'!j.""9~
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<br />D ON< (~1"
<br />
<br />505-12-4643
<br />
<br />
<br />IH""'_9'''$I1'''__1
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<br />VA Medical Center
<br />1lC. CITV TOWNORLOC~TIONOFDEATH
<br />
<br />(lO INSlOE CITY LlUtTS
<br />
<br />
<br />!~Ju(Y1gZ9 Coc1ciI
<br />
<br />
<br />vost>> No 0
<br />
<br />!lO ..soE CITY I.UT$
<br />
<br />Omaha
<br />
<br />, 9a l<ESIOC'-lCE. ST~TE lib COUNTY 9< CITV. TOWN OR LOCATION
<br />
<br />I NE tHall Grand Is1 and
<br />
<br />F.,O.9.W""".9Ia<. ~"'."ooonlo<l,.n ". ANCESTRY '0; _.....00011._..' i 12@r.w<AEO
<br />Ole'ISpec,tyl ISoecilyl I NEVF.~
<br />White American
<br />14. uSUAL OCCUPATION IG_*NOI__duMf_ 14. KINOOfBUSlNESSlNOUSTRV
<br />"'.''''"ng''''. _III_I
<br />Custodian
<br />
<br />Grand Island Public
<br />
<br />2107 N. Sheridan v..lXJ .... 0
<br />o WIDOWED J '3 N....... Of SPOusE 1.- ---
<br />
<br />o DIvORCED The Ima Peden
<br />1" _lXICATIOOl IS,O'''''''''''_\I'_~
<br />Schoolr E---""'~1 '0'21 C<llIogo .'-4",.,-
<br />
<br />FIRST '*00<, loWDEN ~
<br />
<br />16 F.T..e~. NAUE
<br />
<br />FFlST
<br />
<br />LAST
<br />
<br />17 UOTMER
<br />
<br />..-oot.E
<br />
<br />Louis
<br />
<br />Collamore
<br />: 19& ~~ NAME
<br />
<br />Nellie
<br />
<br />LeeIing
<br />
<br />1.
<br />
<br />May
<br />
<br />
<br />Thelma Collamore
<br />
<br />68803
<br />
<br />North Sheridan
<br />
<br />Grand Island, NE.
<br />
<br />f7~~ 1.R;'~::~D":' :::~;}2;~;~i::::;;;;ia1 ~~k
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<br />i Apfel-Buder-Geddes 10'-- D:lc<-..."..
<br />,22rl FuNERAl ~ AlJOAE5,S /SfAt:.ET ~ ~,J= 0 NO ern' OR r~ SU,TF., ~
<br />, 1123 West Second, Grand Island, NE. 68801
<br />i 23 _llIATf.CAUSE 'E"TE"CN!.VO\lECAu$f:""AL.lNtFOo'I..,o. ANO..",
<br />..AR'
<br />I
<br />
<br />Grand Island, Nebraska
<br />
<br />~..a'~~~ ...,.
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<br />Acute arrh thmia
<br />Dlof TO. OR AS A CQt.SEOOENCE OF
<br />
<br />Hin
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<br />....Jr:..~_.,..,.,.....
<br />
<br />I._ Acute coronary syndromf"
<br />'"-* TO OR.os A <:ONSEOVEI4Cl' 0'"
<br />
<br />Days
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<br />.,.....~~... .....
<br />
<br />'<I Atrial fibri lIst ion
<br />
<br />PART OTHEI:l. saC:.W1CIoN1' COMYr.,.,S - ~ ~ t'J:.. ".., W ~'..-.o
<br />.
<br />
<br />126a ,~ OATEOII'_ 1I0Io Dooy v" ,2fi< ><OI.J!IIOf_
<br />I ' I
<br />1 0 Ac:0>00nI 0 -- ! I II i
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<br />jO -... 0 -... 12Ole""-""'YATWORK 1<'60 ~~',t..~""""''''~
<br />:J l-k~'Ot """~ I '(-O,."liJ I
<br />
<br />) . 27, OATlO'" DEATH "*' 01, v'l
<br />
<br />Weeks
<br />
<br />I PA.R,. Mf'" 'EW1.E. WAS Tke~'" I 24 "1..iTOPS"- ! ~ ~"'5 ~....st ~ I'O~
<br />i _GNANCv IN THE PAST 3 UONTHS' : i f.....-.. OI'I~-
<br />1_ 10."', v.. n No D I Vos rn "'" n I v.. 0 .. II
<br />: 2ll<l DESC_1<Cm INJURV OCCURRED
<br />
<br />1l6<l lOCATION
<br />
<br />:,'f"0IIlI~
<br />
<br />SU.T!'
<br />
<br />srREET OR R F D NO
<br />
<br />2Sa OATESlGNfO _ Do. v.;
<br />
<br />1 _ u~: C# OUiT'"
<br />
<br />
<br />2003
<br />
<br />_ 27< TIUE OfOEATH
<br />I
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