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<br /> LOT SEVENTEEN (17), BLOCK TWO (2), IMPERIAL VILLAGE, A SUBDIVISION TO
<br />.---.-- THE CITY OF GRAND ISLAND, HALL COUNTY,' NEBRASKA
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<br />13E1. INSIDE
<br />CITY
<br />LIMITS?
<br />il've.
<br />oNo
<br />17, orA HeR-NAME
<br />
<br />. .
<br />
<br />Roy Mil~er
<br />208. METHOD OF DISPOSITION
<br />D Burial 0 Cremation RAgmO~""'I~im;::$:t~'~
<br />o Oonliltion 0 Other (Spetlify) ,
<br />
<br />2~_
<br />
<br />30. NAME, TITLE ANO MAll_ING ADDA~S8 .~ J;:RTIf=lE, ',. 0: . (..t:P~fPrl"t) -:<" <: "\. ::
<br />G. Scott Smith, !>ID1633M9di~1 Cefrlter Point~la3<::olgFiido Spd.pgs, CO
<br />
<br />:),. NAME; OF ATTENDING PHYSICIAN IF OTHER THAN CERTll"IER (Ty~p(ltU)
<br />
<br />ZIP;
<br />
<br />80907
<br />
<br />3
<br />
<br />o Accident
<br />
<br />
<br />
<br />4
<br />
<br />32. MANNER OF D~ATH
<br />XI Natural d. Pending
<br />lr.v~!:t:g3::0:1.
<br />
<br />5
<br />
<br />o Suicioe
<br />
<br />o Homicide
<br />
<br />34. IMMEDIATE CAUSE IEN
<br />PART
<br />I
<br />CONDITIONS
<br />IF MNWHIC'H
<br />CAVE RISE TO
<br />IMMEDIATE CAUSE
<br />STATING THE
<br />UNDER. VING CAUSE
<br />LAST (c) (G)
<br />PART OTHER SIGNl{'CANrCONOrTI,ONS ~ t:on~tlon.s'aontribjJtir:iQ to dei!i~h,but:not I'nliii.lcd,lo'c:a,~~ if!
<br />II PART lle.g., slcohoLlI.buse, obe$itv, smoke,..), . . ..
<br />
<br />3(1. wYlES we" findings. considered
<br />In'C1et.~nlng cauH of de~tt1?
<br />
<br />Interval between onset
<br />~nd deatll
<br />
<br />
<br />No
<br />
<br />, " ,. ,',' ',', .", "
<br />.'. '.', ': ,,', :: ,. .', .
<br />, .. ......
<br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECTCOPYOfTHEOFFICIALRECOROWHICHIS INMY CUSTODY.
<br />
<br />.....~.....s~
<br />
<br />\iiRONALD S.HY~N .'. .
<br />STATE REGISTRAR
<br />
<br />Do not accept unless prepared on security paper with engraved border displaying the Colorado state
<br />seal and signature of it he Regi,strar. PENALTY BY LAW, $ection25"2-118, Colorado Revised
<br />Statutes, 1982, if any person alters, uses, attempts to use or futnishesto another fOf deceptive use
<br />any vital statistics record, NOT VALID IF PHOTOCOPIED.
<br />
<br />DATE ISSUED
<br />
<br />MAY 08 2006
<br />
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