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<br />"
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlC~S~9]1()N, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .#~~_;j .";;,'~3;~,,
<br />
<br />DATE OF ISSUANCE ~T~i!l~::' ,:_:~. R
<br />
<br />APR 0 7 2006 As:iiii,:ANT $TA"~" ~TtVtR
<br />LINCOLN, NEBRASKA 200607575 HEACTHAND'HuifiANSl!#lllqES
<br />
<br />CKI"'$fD - NAIll!
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<br />..tOO...
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<br />'A"
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<br />"".~ -., -- . . "..,' . . ,<~, 05' 6
<br />."., --; -,' .:::."7'" 6
<br />-;;;.. ...; -;.;....: . ....c...,.. .
<br />,.J + ',' "",,:'~ _ ,_.._.....:--..0-- .,.." 1111 "'",",II
<br />DATE DEATH' "O""H. 0.... ....I'
<br />
<br />............ UI ".... ~...Ial"".
<br />
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />William
<br />
<br />Clarence male I May 17, 1977
<br />UOOOII I 0.., COUNTY Of DEATH
<br />NO;",;;;.' .,.... . I'
<br />s. : lJ3ept. 6, 1914 J. Hall
<br />1i0SPlTAL Oil OTHElllNSflTUTlON NAME, '1I0IO' .'" I"HII. CoIVI ".... ""'0 NuMlI. I
<br />
<br />" Grand Island I. yes r. Veterans Administration Hospital
<br />stAff Of 'lInt ," NO' '" U'.. ....., emUN Of WHA' 65i:iNTiY- MAltIIEO. NEVIll MAll..fO. ~"~ISl.:llVIVIN.-G Sl'Ou$f7.-.;;;;t,'G'-;'---;"IDI" ......I-;--~~---
<br />(O\IM'", wlOO~J). DlvQlIC:EI;l , ""(I" ,
<br />. Nebraska , U.S.A. It Marr1ea "Margaret Layman
<br />SOCIAL sEcuiilvNliMiflt. --. --. -. ustiAl OCMATION ;o~~f .~;;clOI WOH-_tD.,.-;;;-;.;.,----;;O~-- lliN~ofiUslNfss 5ti-INDusTli ._, - u__.. - ....~.---. --.----
<br />_'OOG ..ft, tvlN " ,,"UO ,
<br />It 508-10-2766 ,.. (ret.) plumber .< ,~: Ulo Plumbing
<br />.~$IOtNeE - StAff I eou"NiY .- --- eliY:TOWN:""" OIlOCAYlON -iiOiiOi-e,l'f ....". ISTlEfT AND NUMIEI
<br />. ~'I,:n tIl. Q' "0 t
<br />III Nebraska ,.. Hall ... Grand Island "' Yes ",810 East 15th
<br />, A "'If I NAM/; ...., ,,'OOU .." MAIDEN N"'ME "I" M'OOlt ...,.
<br />
<br />
<br />dec . ) Clarence
<br />. WAS DlCeAUD fYEa 'N us AlIMED 'OKES?
<br />esTtlfrtt" (I~ '-:f:!7il':'41,:~1
<br />
<br />'''IT I DEAtH WAS C.lUSED IY
<br />If _D.... ~-
<br />
<br />
<br />Hancock Ulo (dec.) Dorthea Schillinger
<br />
<br />IN'OllMANT- NAME -IElA'IONS"" - MAILING ADOtESS UIUII 01 I 10 "0, e,\" 0 It, lIP'
<br />".Mrs. Margaret Hancock,wife,810 E.1Sth,Grand Island. NE
<br />
<br />('Nfllt ONl rON' (A USE 'II (INf '0* (0 J. (b /, "'NO Ie"
<br />
<br />
<br />~:~ YO~~~:(~!'s.~;r o,right thigh
<br />
<br />minutes
<br />
<br />';.o,,~~~"::~. ~~,~~~ I (b) Necrosis and infection
<br />,...to,.... e..un '01, I ilVIiO-;-Qi"i,-""(ON,,QVfN(' 0' -------.-------------.--1-
<br />~:.".:~..t..~~: I~~'O..' vascu ar surgery
<br />'el Thrombosis, right superficial artery & subse uent
<br />'All'" O'HII $lGN..l("'N'~t18t.~Iltt~o {tn ,u,~~.... III IF fe*Lt. WAS ''''IRl A AI)T()IlSY
<br />,,, (AUSt G'YJN 'N 'AI' II.' . '1IGN..N(r IN 'HI 'AS' 3 MON'HS? I ,n 01 NO I
<br />Ip artnroplasty 3-15-77)ArteriosclerO,t;is, YeS c. NO [d No
<br />, g*~:Miii' .. iO'ft':'.... ""'. .,.... l)I
<br />c51flitiiOMl1l ~ ,"cu. .
<br />
<br />1 mon.
<br />
<br />
<br />
<br />12 hrs.
<br />
<br />I' YES WUI ""0""" (0"-
<br />$IOIUO 1" Df1lI.u.UMG CAUS>t
<br />01 OIUH
<br />...
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<br />"-
<br />INNltY At W()II(
<br />I ,,,c.n .n 01 "0'
<br />
<br />
<br />..
<br />LOCA nON
<br />
<br />M i 'G11
<br />
<br />. ,tlU' 01 . . 0 "'0. (an o. tOWN. t-U." .
<br />
<br />..
<br />
<br />CEl1lfICATION- _'H 0'" .,..
<br />'"V'CUIN: "
<br />,71',,~;';~;:;!~;~ Fel:!.!._)1, 19'(7 '~..~ 17 J
<br />ettflflC.ATlON-MlDICAl (XAMINfI 01 COIlONfR ON 'HI U,'" O. I'll
<br />flllM.....lOM o. tN, 100' 1:.....0/0l1li ,Nt I"V"'t<io"UON, I.... M" O'.N.O",
<br />D'''''' OCCUIHD ON ..... Cl'1:" "NO 01'" '0 '"' (aUSoli" "..rIO
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<br />eEI'lfIEI- NA/Olf ',....'0". ..,';.,
<br />
<br />,..
<br />
<br />MON'"
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<br />0...
<br />
<br />'If.'
<br />
<br />ANI> ...." "'... ...../.... ...., 0" '010/0'0 NO' ."... IMI DI"'" OCCUIIIO .., 'HI '....CI, 0.. IMI
<br />-,.. D... ..... .00' AfltI 01"'" '''Oul> D.", ."0. to fMt MS'
<br />M 17 1977 d1" d 2. 4Sa 0'''' .NOW"lIIAI.J1.Vt
<br />,\ ay J ". 71,. "" '0'''' (..u"",JIrJlIA
<br />'HI OK'OfN' W"S ,tONOU..C'O 01..0 1 eo
<br />MONI" 0"'" "tA' "OUI
<br />
<br />1977
<br />
<br />"OUI O' O..IH
<br />
<br />
<br />A.. ,~ ""
<br />I SIGN,,'UlIf L 1 )' < (. hi';''' 0. 11111 -"]. DATE SIGNED '''ON'H, 0..., '1..11
<br />t!t.,~ D. DANIELSON~ M.D. "fa .... {-)~~ .J~'--"",,-~uc 5-27-77
<br />:1l~WJsl~~i~' 2201 North Broa8wet'1I;0<':ra:nd Island-;'''Nt'ow~8801 ".."..~ 11'
<br />IUIIAL, elfMA'ION. .MOVAL CfI,\fT .... 01 CIfAUoTOlIY-..NAME LOCAtiON c,,,, O. 'OWN "."
<br />I'~."~
<br />,~ Burial
<br />64fr~~~~'-;~~,.:.~--;~~~;.~-i.I'.- ---..
<br />~
<br />E ""....
<br />U..
<br />
<br />Island, Ne. 68801
<br />
<br />,..?lttty ~ ~ If?.?
<br />
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