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<br />Lot Six (6), in Block Four (4), in Valley View Subdivision in the North Eleven Hundred and
<br />three (1103.0) feet of t~e East Half of the Northeast Quarter (El/2NEl/4) of Section
<br />Twenty-two (22), Township Eleven (11) North, Range Nine (9) West of the 6th P.M. Hall
<br />__ _ County, Ne.~ras~. .,_____.._'
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEII.t, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THEORIO..L}fEt;.Q8IJ....BI,LWlTH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VWM...:...YmB'{~.fitl.9N,WHICH IS
<br />
<br />:::~:::::::~TORY FOR tnTAL RECORDS. ",~~ .i~...:~--.'.;~~j.~?~-:;r.,'~~. ~
<br />1 / 6/2 0 0 4 2 0 0 6 0'7 ^ 18 ;f{'~.-tf7JANLEy.$~cCtioPER
<br />" .ci A-sSlmRTstAfeRE5I!lfflAR
<br />LINCOLN, NEBRASKA HEAL TH~IfD'-tliiMXRBE1if1icE~~TE1rf
<br />
<br />~...~-::. ..~"'._---,. ,.~~, ".;:~._' -~ -= ~-
<br />
<br />STAlE OF NEBRASKA. DEPARTMENT OF HEALTH AND Ht1MAN,sEiPiiaf~ciit~uppQRT
<br />VITAL STATISTICS .- ~:r'.s--, ',c:~' . c;,-
<br />CERTIFICATE OF DEATH' ~:: -~,c:,;~.~-
<br />
<br />'. DECEDENT - 'NAME
<br />
<br />
<br />
<br />2:$EX
<br />Male
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />~. DATE OF DEATH
<br />
<br />Jesse
<br />
<br />James
<br />
<br />Worm
<br />
<br />December 29, 2003
<br />
<br />4. CITY AND STATE OF BIRTH Ilfnot in US.A.. nam. countryl
<br />
<br />Sa, AGE. Last Binnday
<br />IYrs.1 56
<br />
<br />uNDER 1 YEAR
<br />5b. MOS. DAYS
<br />
<br />6. OATE OF BIRTH (Month Day. Year)
<br />
<br />Ord, Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />June 21, 1947
<br />
<br />a.. PLACE OF DEATH
<br />HOS~I~ D Inp"'on'
<br />IiJ ER Outpallen'
<br />D DOA
<br />a. COUNTY OF.DiATH
<br />
<br />OTHER: D Nursing Home
<br />D ReSidence
<br />
<br />D Otl'1er {Sf)eClfvl
<br />
<br />507-56-2266
<br />
<br />Bb. FACILITY - Namo
<br />
<br />(If not in$tiWtion. give sfr"! and number)
<br />
<br />saint Francis Medical Center
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />
<br />Nebraska
<br />
<br />
<br />Grand Island
<br />9.0. RESlOENCE - STATE
<br />
<br />,-, ~..-..-
<br />(Including Zip COde) 90, INSIOE CITY LIMITS
<br />
<br />Cherry St. 68801 Yes IX] No D
<br />
<br />10. RACE ~ (e.g., While. SlaCk. American Indian.
<br />ole,IISp,cllyl Write
<br />
<br />13. NAME OF spouse (If wife, give maiden name)
<br />
<br />American
<br />
<br />Peggy L. Perkins
<br />
<br />14a. USUAL OCCUPATION {Give kind o{ work dono during most
<br />01 working life, even if retired}
<br />Machinist
<br />
<br />16. FATHER. NAME FIRST MIDDLE
<br />
<br />Arlie
<br />
<br />Agrirul.. B:p:rip. Knrf<d:riI:er
<br />
<br />
<br />LAST
<br />
<br />17. MOTHER
<br />
<br />MAIDEN SURNAME
<br />
<br />Zulkoski
<br />
<br />Maxine
<br />
<br />18. WAS D~CEAS~D EVER IN u.S. ARMED FORCES? Vie t N am
<br />(Yes. no. or unk.) /If yes. giVI;l war and dates of services1
<br />Yes Ju1y 25,1967~ 27, 1969 Peggy Worm
<br />
<br />19b. INFORMANT MAILING AOORESS fSTREET OR R.F,D. NO.. CITY DR TOWN, STATE. ZIPI
<br />
<br />824 S.
<br />
<br />St., Grand Island. Nebraska
<br />21a, METHODDFDISPOSITIDN 21b, DATE
<br />
<br />68801
<br />
<br />
<br />21c. CEMETERY OR CREMATORY NAME
<br />
<br />.;:., # 1071
<br />
<br />!iJ Bu'ial D RemOval JanJary 3, 2004 Grand Island City Cemetery
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />All Faiths Funeral Home
<br />
<br />D Cremation 0 Donallon
<br />
<br />Grand Island, Nebraska
<br />
<br />22b, FUNERAL HOME ADDRESS
<br />
<br />ISTREET OR R.EO. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />2929 S. Locust St_, Grand Island, Nebraska
<br />
<br />68801
<br />
<br />23, IMMEDIATE CAUSE
<br />P~RT CARD lAC ARRE S T
<br />'01
<br />DUE TO. OR AS A CONSEQUENCE OF'
<br />
<br />IENTER ONLY ONE CAUSE PER LINE FOR lal. fbl. AND (ell
<br />
<br />I Interval between onset and death
<br />: 40 MINUTES
<br />
<br />I
<br />I Interval between ariSel ana death
<br />I
<br />r'
<br />I
<br />I IntSrval between onset and det>th
<br />I
<br />I
<br />I
<br />25, WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />(bj
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />II THROAT CANCER
<br />
<br />2lia,
<br />
<br />
<br />2Ilb. DATE OF INJURY {Mo" Day. y,,} 25e. HOUR OF INJURY
<br />
<br />o Accident 0 Undetermined
<br />o Suicide 0 J)endlng 26e. INJURY AT WORK
<br />o Homicide InvestIgation Yes D No 0
<br />
<br />26g. LOCATION
<br />
<br />STREET OR R,FD. NO.
<br />
<br />CITY OR TOWN
<br />
<br />~~
<br />h,:
<br />8 ~i5
<br />t
<br />
<br />27.. DATE OF DEATH {Mo" Day, Yr.}
<br />December 29, 2003
<br />
<br />28a, DATE SIGNED (Mo.. Day, y,.)
<br />1-2-2004
<br />
<br />28b TIME OF DEA TH
<br />12: 5 1
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<br />
<br />%'11>. DATE SIGN EO IMQ.. Day. YO
<br />
<br />.270. TIME OF OEATH
<br />
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />cause(sl stated.
<br />
<br />ISI natu.re and litla} ...
<br />DID T08ACCO USE CONTRISUTE TO THE DEATH?
<br />
<br />DYES D NO I)a' UNKNOWN
<br />
<br />31 NAME AND ADDRESS OF CERTIFiER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />
<br />~ NO
<br />
<br />JEROM E. JANULEWICZ, HALL COUNTY ATTORNEY, 231 S. LOCUST ST, GRAND ISLAND, NE 68801
<br />
<br />32., REGISTRAR 32b. DATE FILED BY REGISTRAR {Mo..DBY, Yr.}
<br />JAN 5 2004
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