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WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND HUMAN SERVICES
<br />SYSTEM[ /T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S {M 111 1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE F'r=
<br />�AANLEYS. COOPER -
<br />12/8/2003 200609819 ASSIST, NTSTOtAEO1S RAR7 �_ _=
<br />LINCOLN, NEBRASKA HEALTH AND HUMA*3ER0CXS *MW EAC-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIM IN :SUP OR
<br />VITAL STATISTICS 13579
<br />CERTIFICATE OF DEATH
<br />LL 0, PUNCH AL MUMC AUUHtz]3 I ts( MCC( UM H.Y. U. NU.. LI I Y UH UWN, J1 A I t, �1M)
<br />601 North Webb Road, Grand Island, NE 68803 -4050
<br />L:1. IMMCUTA I t I+AUSr
<br />PART `
<br />I
<br />(a)
<br />`' DUE TO, OR A A CON ENCE F'
<br />T (bl
<br />rrll
<br />JEN ICH UN(LY tJNk U 1St YkH LINT rUH la). (b), ANU (C))
<br />J_ )
<br />I Interval between OnSet and deals
<br />I
<br />I Interval between onset and deals
<br />i
<br />I
<br />Interval between onset and dealt,
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3.-DA'!E OF DEATH 1Monrh. Day. Year/
<br />PART PREGNANCY
<br />Daniel LeRoy Arp
<br />Male
<br />December 1, 2003
<br />4. CITY AND STATE OF BIRTH 111 nol m U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH IMonth. Day. Year/
<br />St. Paul, Nebraska
<br />(Yrs1 50
<br />5b. MOS DAVB
<br />Sc.HOURS MINS.
<br />April 27, 1953
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -70 -1041
<br />HOSPITAL. ❑ Inpatient OTHER. ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name /Ilnnf mafituhon, give street and numtler/
<br />2515 Pioneer Blvd.
<br />❑ DOA ❑X OtherfSpecav) unP
<br />8C. CITY. TOWN OR LOCATION OF OEATH
<br />Stl. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island _
<br />You NO ❑
<br />Hall
<br />9a, RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d, STREET AND NUMBER flnc)uding Zlp Cdde/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2515 Pioneer Blvd. 6880
<br />Yes 11 No ❑
<br />10. RACE - (e,g., White, Black, American Indian,
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (u woe, grvemarden name)
<br />etc.l (Specify) White
<br />White
<br />(Spearyl American
<br />NEVER DIVORCED
<br />Charmaine Parsons
<br />fif I
<br />MA
<br />14a. USUAL OCCUPATION IGive kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />27d To the best of my knowledge, d fnF Cc rte at thttim da and place and due to the
<br />Elementary or Secondary (0 -121 College 11 -4 Or 5 -1
<br />Production Supervisor
<br />Machine manufacturing
<br />12
<br />15. .FATHER -NAME FIRST MIDDLE LAST
<br />1 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Kenneth Arp
<br />Mary Cook
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes, no, or unk.) (If yes, give war and dates of senrides)
<br />No -- --
<br />Charmaine Arp__
<br />30.b WAS CONSENT GRANTED?
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F D. NO,. CITY OR TOWN. STATE. ZIP)
<br />x ❑ YES ❑ NO UNKNOWN
<br />2515 Pioneer Blvd., Grand Island, NE 68801
<br />X ❑ YES V0
<br />20.E ALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />32a. REGISTRAR
<br />® Burial [:]Removal
<br />ecember 4, 200
<br />Grand Island City Cemetery
<br />DEC 42003
<br />22a. FUNERAL NOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY UR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />❑Cremation ❑ Don ato^
<br />Grand Island Nebraska
<br />LL 0, PUNCH AL MUMC AUUHtz]3 I ts( MCC( UM H.Y. U. NU.. LI I Y UH UWN, J1 A I t, �1M)
<br />601 North Webb Road, Grand Island, NE 68803 -4050
<br />L:1. IMMCUTA I t I+AUSr
<br />PART `
<br />I
<br />(a)
<br />`' DUE TO, OR A A CON ENCE F'
<br />T (bl
<br />rrll
<br />JEN ICH UN(LY tJNk U 1St YkH LINT rUH la). (b), ANU (C))
<br />J_ )
<br />I Interval between OnSet and deals
<br />I
<br />I Interval between onset and deals
<br />i
<br />I
<br />Interval between onset and dealt,
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />111 IF FEMALE. WAS THERE A
<br />24 Au70P5Y
<br />25. wA5 CAST REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages 10 -54) Yes No
<br />14. No
<br />V_ Yes Np
<br />26a.
<br />26b. DATE OF INJURY (Md., Day. Yr./
<br />28c. HOUR OF INJURY
<br />26d., DESCRIBE HOW INJURY OCCURRED -
<br />Accident ❑ Undetermined
<br />M
<br />Suicide Pending
<br />26e, INJURY AT WORK
<br />28f. PLAC� QF. INJURY - At home, farm, Street, factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ Homicide Investigaton
<br />yes ND
<br />❑ 1:1
<br />office udding. etc. lSpecily/
<br />27a. DATE OF DEAT /Mo.. Day. Yr.)
<br />28a DATE SIGNED (Mo.. Day. Yr.)
<br />28b TIME OF DEATH
<br />M
<br />27b. DATE SIGNED (Mo.. D_ ay. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD lMo.. Day. Yc)
<br />28d. PRONOUNCED DEAD tHourl
<br />i G
<br />fif I
<br />•O. %/ ` M
<br />M
<br />$ice
<br />°�,
<br />27d To the best of my knowledge, d fnF Cc rte at thttim da and place and due to the
<br />250: On the basis of examination and,or investigation, in my opinion death occurred at
<br />° °
<br />cause(sl stated. \
<br />the time, date and place and due to the cause(s) stated.
<br />1 nature and Title) ► •' r
<br />(Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE YO 7 E IlEAYW
<br />3 .a HAS DRGAN OR TISSUE DONATION 8EEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />x ❑ YES ❑ NO UNKNOWN
<br />❑ YES aNO
<br />X ❑ YES V0
<br />31. NAME AND ADDRESS Or CERTIFIER IIPHYSI AN, CORONER'S PHYSIC( N OR COUNTY ATTORNEY) IType or Print
<br />5 ' r � L i . � ' � � � � 4• c' �� � n Gl� -, � 1 • � r� !G` � i5 �/�'.3
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR fMo., Day. Yr.)
<br />DEC 42003
<br />11
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