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<br />
<br />Rev, "197
<br />
<br />..
<br />
<br />2 0 0 7 0 1 4 9 tATE OF NEBRASKA- DEPARTMENT OF HEALm AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />, DECEDENT - NAME
<br />
<br />FIRSl
<br />
<br />M'DDlE
<br />
<br />lASl
<br />
<br />2 SEX
<br />
<br />3 DATE 01= nEAtH IMo"fh 'My Y~a'J
<br />
<br />Merrick Count
<br />7. SOCIAL SECURTlY NUMOER
<br />
<br />
<br />
<br />Clarence
<br />.. CllYANDSTATEOFOIRTH (NnclInUS,A..",,""CCN<IIryI
<br />
<br />Male
<br />UNDE'" DAY
<br />.... HOURS' MINS
<br />
<br />2002
<br />
<br />. 508-30-8392
<br />
<br />0 InDaIIB"' Q!~~R 0 Nutsmg H()ITlt;>
<br />0 ER Outpatient ~ R4ISldenl;:t!'
<br />0 DOA 0 011'19115Vf"c/f\iJ
<br />
<br />
<br />8b f:"ACllITV. NAme
<br />
<br />'" nOI H'I!titvtktn give 6tr.~' ,f'I(t I1wnbMJ
<br />
<br />2724 West ColI
<br />". CIlY TOWN OR lOCATION OF DEATH
<br />
<br />e
<br />
<br />ge INSIOE CITY liMITS
<br />Ye;~ No C
<br />13 NAME OF SPOUSE ,If 'kI'f', olVf makWn name}
<br />
<br />CUst
<br />FIRST
<br />
<br />.~ EDUCATION ISooe,ry",,'Vh'
<br />EJi!rl"\!nl"ry Qf S~hnl:I"rv 10, i"
<br />8th Grade
<br />MIDDLE
<br />
<br />st grlde complete<ll
<br />CoIJeg@ /1." ()t' ~'1
<br />
<br />MIDDle
<br />
<br />lASt
<br />
<br />11 MOTHER
<br />
<br />MAIDEN SURNAMe
<br />
<br />Petzoldt
<br />'9. INFORMANT. NAME
<br />
<br />Ella
<br />
<br />Mettenbrink
<br />
<br />NMI
<br />
<br />Eleanor Petzoldt
<br />ISTREET OR RF 0 NO.. CITY OR TOWN. StAtE. ZIP)
<br />
<br />Grand Island Nebraska 68803
<br />2'. METHOD OF DISPOSITION 2.b DATE
<br />
<br />2'e ceMETERY OR CREMATORY NAME
<br />
<br />B 0"';01 0 Romo,AI A r. 16 2002 westlawn Me1rorial Park CeI
<br />21d CEMEteRY OR CREMAlORYlOCATlON CIlY OR tOWN STATE
<br />
<br />Kleine Funeral Hare 0 C.omll"" 0 00031<>0
<br />22b. FUNERAL HOME ADDRESS IStREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP\
<br />
<br />Nebraska
<br />
<br />Grand Island,
<br />
<br />
<br />
<br />Natural
<br />
<br />causes
<br />
<br />III
<br />DUE TO, OR AS A CONSEOUENCE OF
<br />
<br />Ibl
<br />DUE TO. OR AS A CONSEOUENCE OF'
<br />
<br />26,
<br />
<br />
<br />lei
<br />OTHER SIGNIFICANT CONOlflONS . ~ition, contributing k) 1he death bu1 no1 'elaled
<br />PART
<br />II
<br />
<br />26b OA TE OF INJURY 11./0.. DIY, y,.} 26e HOUR OF INJURY
<br />
<br />o
<br />o
<br />o
<br />
<br />AcCldenl 0 Undetel'mln8d
<br />~nir:ide 0 Ptmdil1g
<br />
<br />26e INJURY AT WORK
<br />y" 0 N'O
<br />
<br />26" TlMEOFDEATH approx
<br />
<br />10: 00 m M
<br />28<1. PRONOUNCED DEAD (Hoo"
<br />
<br />21:19. lOCATION
<br />
<br />STREET OR RF .D. NO
<br />
<br />CII Y OR TOWN
<br />
<br />SlA TE
<br />
<br />Inves:ligalion
<br />
<br />Homicide
<br />
<br />
<br />amM
<br />
<br />
<br />21.. DATE OF DEATH (Mo.. DIV. Y"
<br />
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<br />~~u
<br />u "
<br />
<br />Ii. no ""~"" "" ",,,, ", ,,~~~'"
<br />
<br />
<br />~ J 27d 10 lhe tltsl of my knowledge de.1h O(curred I' the "me! d*lt aM place and due 10 1t'l8
<br />causel'$! ,llIled.
<br />
<br />IMe). D3Y. y, I
<br />
<br />M
<br />
<br />29
<br />
<br />
<br />J'. NAME AND ADDRESS OF CE"TIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY A nORNEYI (TYP* or P,m"
<br />
<br />68801
<br />
<br />Sgt E G Edwards, GIPD, 131 S Locust, Grand Island, NE
<br />
<br />32.. REGISTRAR
<br />
<br />32b DATE FilED BY REGiStRAR IMo, Day. Y,I
<br />
<br />FOR VITAL 8T A TISTICS USE ONLY
<br />
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