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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD QtI FILE WItH
<br />THE NEBRASKA HEAL tH AND HUMAN SERVICES SYSTEM, VITAL STA TISTlCS. SJreTImI;~WHlCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. M~1J.2:,f:t-"~t:ii;.}-
<br />
<br />
<br />";~;;~:3 200607890 ':::l/J:i:~~~\
<br />LINCOLN, NEBRASKA HEAL TH AND Ht!MA~SERVlCES-,rSr~ 2J
<br />
<br />,- - ,,- .'. ~.
<br />STATE OF NEBRASKA- DEPAR~ T OF HEALTH AND HUMAN SERVh:sFi#..meE~~sUPP9RT
<br />CERT~~;;~~~~EATH- ,m,_ ---"'=~'03 11603
<br />
<br />1, DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2, SEX
<br />
<br />3. OArE. OF OEATH (MOtl/n. Day. Year)
<br />
<br />Margaret
<br />
<br />J.
<br />
<br />Halpin
<br />
<br />Female
<br />
<br />October 1, 2003
<br />
<br />Greeley, Nebraska
<br />
<br />.. 7, SOCIAL SECURTIY NuMBER
<br />.j
<br />1 505-58-0598
<br />
<br />] 8b. F=ACILlTY - Name (It not institution, give str9B( and number)
<br />
<br />" St. Francis Skilled Care
<br />'1
<br />
<br />72
<br />
<br />UNDER 1 YEAR
<br />Sb. MOS, DAYS
<br />
<br />UNDER 1 DAY
<br />50, HOURS' MINS.
<br />
<br />6, DArE OF 6IR1'H (Month.Oay. Yoar)
<br />
<br />4. CITY AND STATE OF BIRTH IIf no/in U.SA, name r;CunftyJ
<br />
<br />5a. AGE - Last 6irlhday
<br />IY""
<br />
<br />July 22, 1931
<br />
<br />Bo, PLACE OF DEATH
<br />HOSPITAL: 0
<br />D
<br />D
<br />
<br />Inpatient OTHER, [ZJ NurSing Hom!:!
<br />ER Outpatient 0 ReSIdence
<br />DOA 0 Other (SpeC/11I1
<br />
<br />MIDDLE
<br />
<br />
<br />Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />
<br />68801
<br />
<br />Yes fXJ No 0
<br />
<br />9a, RESIDENCE - STATE
<br />
<br />COUNTY
<br />
<br />9d. STREET AND NUMBER (Including Zip Codel
<br />
<br />ge INSIDE CITY LIMITS
<br />
<br />1 O. RACE" (e.g., White. Black, American Indian.
<br />etollspeoitvWhi t e
<br />
<br />11. ANCEsrAV (e.g. Italian. Mexican. German, etel
<br />ISpoeifyh' MIrish
<br />
<br />1:3 NAME OF SPOUSE (If wife, give m~iden /tams)
<br />
<br />.]
<br />
<br />14a. USUAL OCCUPATION (Give kind of work done during mosf
<br />01 wotk/tlg IIf8, sven if retired)
<br />
<br />Owner/Mana er
<br />
<br />FIRST
<br />
<br />Stephen Mw Halpin
<br />
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary or Sec:ondary 10-12) College 11-4 Or ~"'l
<br />12 0
<br />
<br />:<II
<br />Ii 16. FATHER - NAME
<br />
<br />..
<br />
<br />41
<br />
<br />. 18. WAS DECEASED EVER IN U.S, ARMED FORCES?
<br />
<br />lY~O' or unk..) (If yes. fJ1vtrtAM dates of services)
<br />
<br />17. MOTHER
<br />
<br />MIODL!::
<br />
<br />MAIDEN SURNAME
<br />
<br />John
<br />
<br />Mary
<br />
<br />Maloney
<br />
<br />Halpin
<br />
<br />19b. INFORMANT
<br />
<br />MAiliNG ADDRESS
<br />
<br />105 W. 20th St.
<br />20, EMBALMER - SIGNATUR" & LICENSE NO.
<br />
<br />Grand Island, Nebraska 68801
<br />21., METHOD 0': DISPOSITION 21 b, OA TE
<br />
<br />210. CEMETERY OR CREMATORY NAME
<br />
<br />
<br />IX] Burial D Removal Oct. 3, 2003 Westlawn Memorial Park
<br />210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Curran Funeral Cha el
<br />22b, FUNERAL HOME ADDRESS ISTREET OR R-F,D. NO, CITY OR TOWN, ST ATE, ZIPI
<br />
<br />D CrematiOn 0 Donalion
<br />
<br />3826 W.
<br />
<br />Stolle
<br />
<br />Park Rd.
<br />
<br />G.I.
<br />
<br />NE
<br />
<br />68 63
<br />(
<br />
<br />
<br />Grand Island, Nebraska 68801
<br />IE ER ONLY ONE CAUSE pER LINE FOR lal. Ibl, AND (ell
<br />
<br />.. \. <.)(~
<br />
<br />Interv.cr.1 between onset and death
<br />
<br />-,
<br />
<br />'S.
<br />
<br />Interval be1wee set and death
<br />
<br />I
<br />I Interval between onset aM death
<br />I
<br />I
<br />I
<br />25, WAS CAS" REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />26a.
<br />0 Accident 0 undetermined
<br />0 Suicide 0 Pending
<br />0 Homil;ide Inves1igation
<br />
<br />26g. LOCATION
<br />
<br />STREET OR R,F,D. NO,
<br />
<br />CITY OR TOWN
<br />
<br />STAH
<br />
<br />~. DATE OF DEATH (10,10.. DOy. yt.)
<br />October I, 2003
<br />
<br />26a, DATE SIGNED (Mo. D,y y,.)
<br />
<br />2Bb. TIME OF DEATH
<br />
<br />31.
<br />
<br />
<br />8:50am
<br />
<br />sU
<br />1~0
<br />I>=>-
<br />"-<~
<br />ffi~6
<br />1ii3"
<br />;?:38
<br />u"
<br />
<br />M
<br />
<br />_ $z
<br />i -g~
<br />.. ~>';l-
<br />_ E if ~
<br />- 8 :"'0
<br />:n
<br />i ... ~
<br />J
<br />
<br />DATE SIGNED (MO.. Day, Yr.J
<br />
<br />28e. PRONOUNCED DEAD (MO.. Doy, Yr.J
<br />
<br />2BO, PRONOUNCED DEAD (Houri
<br />
<br />M
<br />
<br />M
<br />
<br />28e. On the basis of examinatIOn and'or investigation, ill my opinion dealh occurred at
<br />the hme. date and place and due to the cal,lse!sl sta1ed_
<br />
<br />~.
<br />
<br />~b WAS CONSENT GRANTED?
<br />DYES ~
<br />
<br />Ryan D. Crouch M.D.
<br />32a. REGISTRAR
<br />
<br />NE
<br />
<br />68803
<br />
<br />32b, DATE FILED BY REGISTRAR (MP.. D,y, y,,)
<br />
<br />OCT 1 6 2003
<br />
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