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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN -8ERVlCES
<br />'_ SYSn;M,/T CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQJiD-oHFJi:Ji'W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIGS-:sironON.WHIt:Fns
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~,~.~::,~ ~-;f:::'~''-~~~--~~-''\
<br />DA'rEOF1SSUANCE -~,' ."- -: . -'~_'i'''-_
<br />'1 . -- ::~'~ '::;;
<br />
<br />OCT 1 5 2001 20060843 6:;-( ~~~cPO~ ~~
<br />ASSI$.TAlit STArE'REt;lsTRAR ~~
<br />LINCOLN, NEBRASKA HEAL TH AND H~if,j-~ERY'PES~Y~rit~,Z
<br />STATE Of NEBRASKA. DEP AR TMENT OF HEAL rn AND HUMAN SERV\ci!S FINANCt'"MibSlJpPOH
<br />CERTI;;~S;~~;~EATH '7_ '--~'-~-_,,~_~~~~bl 11220
<br />
<br />"1lJE:ClLlLNl NAM[ - -- -.-.-.,---------'~:;r-- ___,__n__--'---MIUOI F. --~ 1_ ;_~s_~x -1- e -[DATE OF OcDEATt" o'Mber''''"' 0,,, ~'e,'::Ir)
<br />
<br />__ ... _.. Ve!:r-l~_ B.__ Jo~~on ...... _ 2?~~______
<br />4 CIlY"ANO STATF OF.. BIH111 1I/;lotll1 USA Il,Wlt:'?COUl1lrv:'----_. . T... S.l N.lt.. Lasl OllihddY ~~.ER.l_Y!:::AH uNDEn 1 DAY 6 DATE OF BIRIH-,1Monlh. Oa\~'!!i1rl
<br />(Yr,=", \ !ib MOS. I OAY5 Sc; HOURS . M'iNS
<br />Dannebrgg, Nebraska ____ d_ _ __ 82 _: __ __~ugust 2.L___~_~___
<br />
<br />7 SOCIAL Si::CuAlIY NUMBF.n ....I.<1. r..".A..~~.O.~..:I~::,lH Irlpiillell! 0lHI:.8 ~ Nur::'!'H.1110rn+.\
<br />508-18-9497________ DO 0
<br />8b ~ACIUTY Name IlfIJotlr1sMurion. givp.5Irp.p.fdndrlumberJ .,,_" lH Oulpatlent Rt!Slde~lU'
<br />
<br />Beverly H~lthcare at Lakeview n DOA 0 C~''':'__~~:---------
<br />
<br />8e CI~;:~R L;:;~~~EATH -18" ~:'D~Y~~M'D T"'COUNTY OF OcATH Hall county------
<br />9a-=~s::=rcrnmlY-1l _--[:_c:'-r~:::lO~:'~~d SIHEETANDNUM;: '1,:"~",g~~;;1 - --c :::'nRJTYN:,'M~-
<br />
<br />10 nAC!: _ (e,g" White, BI38K Arnf!fl!.:;an Indlcln 11. ANCFS T HY I~:,l.l I!alian, Ml-!xlean. Germnn, elf: I 12 [;C'! MArH1IED 13 NAMF OF Sf-'OUSE ,:/f wilt') II!VP. m;I!{M!llIiJll1(~/
<br />.t< ,'S"'C'~' 'Sp,,,"" Am . 0 NEVER Erma I. Chadwick
<br />White er~can... MAHH'ED________.
<br />. 14011 USUAL OC'CUPATION IGIV~ k.1r1dol wOfk a01l1] aurmq mo,,>1 . -L"..',',...K.__'_ND OFARUgS_r'.N.,F~'.SScu' IN~OlUSt'rRurY e
<br />ollNorklfJ(J life, even If fIN/tea) CCllleq\-! :' 1 .: I)' ,.
<br />Farmer
<br />
<br />16 _~A.'HEA-NAME.- ~::t____NM1MI[lD:Qhr~sonLAST- --eTHCR ;~::'RST
<br />
<br />18, WAS DECEASED eVEn IN tJ S ARM[O fORCeS? WWlr i 19C1 INFORMANT. NAMI:.
<br />
<br />I IYy~~O' ",k[ I"oY'8l'1e 171"9"42' ';~'C";i 2/18/ 184} .... 'I E~~ J~rmso~__ ______.
<br />
<br />19t1 INf-URMANT MAILING AOOFlfSS ISTREfT OR H,~' 0 NO, CITY OR TOWN ~; J'f\ f[, Zlrl
<br />
<br />
<br />MAIDEN ~:;i'j'R-r:,iAME
<br />
<br />K.
<br />
<br />t~isS2n
<br />
<br />2809 W. State Street Grand Island, Nebraska _ 68803
<br />2Q" r:MBALMER . 5IGNATUR[ 8. UCENSF NO -, ~;".-:-" i .,~ ~~..; {.r/ 21 a METHOP OF OISPOSITION ;?lh DAlE I 21c CEMETERy ORCR~'MA lOR,. NAMF
<br />\j- 'I ,j- 1
<br />_,~ j..-,,""",'< -- '" yr') /l~/:'--_-m-- rxJ S,,,.' 0 He'"'''''' Q<;t. 5, 2001_ Westla\<ffi Memorial n~ark_
<br />22" fuNERAL HO'~AM! ' I ?1 d C[METE~W on cnEMA1()HY LOCA TlON 1::11 y .:m TOWN 5T r\ TF
<br />
<br />_.----.Klei ne Funeral~_____ .. 0 ",,'"'''uC 0 noo,,,,,, Grand_ Island_, . ~ebra:;ka
<br />22b FUNERAL HOME AODRI::.SS (STREET OR n F 0 NO ell Y OR TOWN ST A fE.lIPI
<br />
<br />
<br />rth_ Front Street, Grand Isl@.Q_,-_ Nebra;;}gl
<br />IMMEDIATF CAUSE r1 F-H ONL Y ONE CAIISr- f-'LH LINE Fon III Ihl AND Ie I)
<br />
<br />,P~RT" lY\'v'- \\-\. l..,.'i -J<'?<,-':-':-':~ '. /~ \\iI,\{ (: _
<br />r---- DuE TO. OR AS A co"N-S"EOU-ENCE or ----
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<br />(~I~ ~-~.: o;~ (t~\~~_L1
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<br />DuE TO. OR AS A CONS[QU[NCE OF
<br />
<br />~\.,\v lW\lt(\. t\t\ 'C
<br />
<br />68803
<br />
<br />InterV,11 betwe~n (1n!',~1 il'lU ~~I-:-.,lr)
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<br />Inlerv,,1 t)~tweerl orl:il,' ilr~'J '.~'C'<\1I"
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<br />-. (HHI:H SIGNIFICANT CONDITIONS - Cor)dl!lo;';-s'.'contfibuting 10 It~~ -doa'ih-t;ut ~ot related ., t--;:- 2-;~.'-
<br />P~IRT(\ ~t\}l") ,~e.h\,?'~ ""\...~,,\~\!~ \'\~~..bt)_. (Age, 10 ',4[ Ycs Ye,n N" [}d
<br />
<br />~ Acc,denl 0 U'"eI",,,,,"cd 26~ DATE;~'N~\R~M" Oay. Y'I ?fk HOUROFINJU.R.Y_",-_ L"" -D[SC~'BF_~~WINJURYOC~UR:=--__
<br />
<br />
<br />
<br />[l SUIcide 0 pendll'lQ 2i1p. IN,Jl)RYATWOAK 2fiq, LOCAl ION ~rAEETORRFD NO
<br />
<br />[..J HomICide 1r1\1'eS'U;l(:llI~m YHS t] NO 0
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<br />2~~ ~AAS~i::~~ ~~F~6~(~~:~! MFOICAl.
<br />~Ll N.o~
<br />
<br />(;lfy OR TOWN
<br />
<br />STATE
<br />
<br />2~a DA TF Or-: OEA Tt'1 (MO 0,'11' Yr)
<br />
<br />2Aii IJA T E SIGN[D (Mo, O(iV Yr)
<br />
<br />I ?Ah TIM~"Of~ DCA TH
<br />
<br />I
<br />
<br />21b DATE 51GNED IMo.. Day Y'I
<br />
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<br />\D-- \ ~ ()\
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<br />I ~ ~:.- 28c PRONOUNCED DEAD (Mo, Day. 'It.}
<br />
<br />~~;:~
<br />u cc~, 0
<br />M ~ ~ 3
<br /><.~d To the bf!sl ol my l<:now IJlaec and duc to tho::! .:2 ~ ~} :7.8e Or1!he basis of 9)(amlnatlon and:or investigation, in my oplnlOr'I dCi1lh oecllrred fit
<br />CaIJSel;-,!5Iaten i'V\/V\lv,..r~ (:) =' lhe lime, dal~ and pl~c:e aM due 10 the c::ausels) stated
<br />
<br />151 nature nnrl TilI~) .. < ,) _' ISlqnature and Tilte) ..
<br />DID TOBACCO-USE CONTRIBUTE r: ------ 30.' HAS ORGAN 0 TISSUE DONATION BfEN CONSIOERED?
<br />
<br />o Y"~ D NO ___ _ ' '~_N()
<br />
<br />31 NAMf AND ADORE::SS or CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COuNTY A HORNE. v) (r ype Or' Printl
<br />
<br />28d PRONClUNCED DEAD
<br />
<br />(HfJUrI
<br />
<br />M
<br />
<br />
<br />I 30~\WAS CONSENT ORAN lEU I
<br />o YE~
<br />_.~ ----
<br />
<br />[&NCi
<br />
<br />Steven L.
<br />32<:i~ QEGlSTRAR
<br />
<br />Husen _I:ID~ 16 ~~' _ Grand
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />Island,
<br />132b
<br />i
<br />
<br />OA T E: FILE:.D By REGISTRAR (Mo" Dav. Yr'.)
<br />
<br />OCT 1 2 2001
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