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<br />WHEN THS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ..AII\..uI......, ,/flFRVlCES
<br />SYSTEM, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALRECQAl) OHF1LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAUSl/CSSEC'i'JOtI,.'WffICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~:,Y".-:"'.'-<O :~."~ J.::/iLi.'."'"
<br />F", fJ.~h
<br />DjUlFSSOZ001 200708028 ~~sTA~f:r1fliE.fg~~
<br />LINCOLN, NEBRASKA HEALTH ANElHUMAf!,S~'!!'f'"~SWEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEAL 1lI AND HUMAN. Spl....YI. CES.F1N:.. ~.C.~ ~.'~o- SUP~RT.
<br />VITAL STATISTICS . ,~.c". ..,,,::c" U 1 0 816 2
<br />CERTIFICATE OF DEATH "..c~'.o;:.,-=- -
<br />
<br />3 nATf OF DEATH \-/Orit!' Ucl~. 'r"eal"/
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<br />I-[)[(,[[>[Nf NAME -~-----:O:T~----'
<br />
<br />
<br />[.". CiTYAND 51 AlE" OC BiR I H III 001., uSA.. oam. cou""yj
<br />
<br />MIDDLE
<br />
<br />lAST
<br />
<br />SEx
<br />
<br />David
<br />
<br />Ma1e
<br />UNDER t OA Y
<br />~c, t\OURS--"'~'.MiNS
<br />
<br />Ju1y 22, 2001
<br />6 DATE or BIRH1 (Month. Day ~ie,l(1
<br />
<br />C1ayton
<br />UNDE'A , YEAR
<br />'~b MOS I DAYS
<br />I
<br />
<br />February 13,
<br />
<br />
<br />Grand Is1and, Nebraska
<br />7 SOCIAL Sl:::CURrlY NUMB[R
<br />
<br />HOSPITAL 0 lr1pi:l'I~n!
<br />
<br />o FR Outpatient
<br />
<br />o DOA
<br />COUN'JY Of- Dt::ATH
<br />
<br />0'1 HI::R [K] NurSing Homt'
<br />
<br />o Rl;!'!)Ic1ence
<br />
<br />o Othel iSDI:\::fv:
<br />
<br />508-16-9085
<br />
<br />tit! r A"6L."i"T"y ,.~ 'N'j~.;e----'--.~~-(I( not Im:;;tIMion, give street ana number)
<br />Tiffany Square Center
<br />
<br />Bc en y TOwN OR l OCA TlON OF OF:A TH
<br />
<br />
<br />Grand Is1and I
<br />90 HESIDENCE ST ATE 19b COUNTY
<br />
<br />Nebraska Ha11
<br />~~~~_ n
<br />
<br />"...'~~ ..~~1,_',"__~',~ ..............._'''''~
<br />
<br />9d, STREET AND NUMBER (fnC/(Jding Z/{J Coael
<br />
<br />Grand Is1and
<br />12. ~l MARRIED
<br />
<br />D NEvER
<br />MARRIE:D
<br />Hlb KIND OF BUStNE::$S INOuSTRy
<br />
<br />i 3 NAME OF SPOuSE (If wile, .GIVe male/en flamel
<br />
<br />10 RACe" (e,g White. BlacK" A.merican Indian
<br />elc) !S~"H)CIIy)
<br />White
<br />
<br />" ANCESTRY Ie g.
<br />IS!'H'(.lfyl
<br />
<br />
<br />C1ayton
<br />
<br />f4a USUAL OCCUPATION {Give I(indo! work done during most
<br />01 workmg tiff,?, eVf;!n If retirt;:!d}
<br />Phannacist
<br />
<br />16 FATHFR-NAM~
<br />
<br />17 MOTHER
<br />
<br />MIDDLE
<br />
<br />MAlnFN SURNAME.
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />wi11iam
<br />
<br />Grace
<br />
<br />zinn
<br />
<br />E.
<br />
<br />18 WAS ULC~A.S'['O"-[l/'E~INU:S:'-A~iMED FORCES?
<br />IYN~")' or I,Jnk,) I III )lP.::; give war and ddli:!s of ::;erVll:~esl
<br />
<br />._""._.---L...-_~'"~ ."'~".'...' .~.".,'.".~
<br />19b INj.:Of:lMAN r MAILING A.DDRESS
<br />
<br />NAME
<br />
<br />E10ise
<br />(STREET OR R F D NO. CITY OR TOWN STATE. ZIPI
<br />
<br />
<br />Grand Is1and, Nebraska 68801
<br />2" METHDO OF DISPDSllIDN 21 b. DATE
<br />
<br />21c C~M~"ERY OFtCRFMATC)RY.'" NAME
<br />
<br />[Xl Buria.l
<br />
<br />o Remov;;:ll
<br />
<br /># 107 1
<br />
<br />Ju1 25 2001 Grand Is1and cit
<br />21d CF.Ml::TERY OR (REMATORY LOCATION ClTv OR TOWN
<br />
<br />A11 Faiths Funera1 Home
<br />
<br />o Cr~mallon 0 DO/'Iallorl
<br />
<br />Nebraska
<br />
<br />Grand Is1and
<br />
<br />2:?b FUNE:RAL HOME ADDRESS
<br />
<br />ISTREET OR R.F.o. NO CITY OR TOWN STATE. ZIPI
<br />
<br />2929 S. Locust St.,
<br />23 IMMEDIATE CAuSE
<br />PART
<br />I '" '1-{;\,t?~,ft,
<br />DUE TO. OR AS A CONSEOUENCE OF
<br />
<br />Grand Is1and. Nebraska 68801
<br />{ENTER ONLY ONo CAUSE pER LINE FOR lallbl. ANO lell
<br />
<br />Interval between onset ,1.f.C: (If:'!;;:IW
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<br />w..............._~','_~
<br />gf:'! INSIDt CITY LIMIT S
<br />
<br />Y.5 I&J No 0
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<br />
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<br />STATF
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<br />Inter'val bolwoon onsel and oe:::Ilf'
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<br />DUF T
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<br />OIHEH SIGNIFICANT CONDITIONS.
<br />PART \
<br />"&~~'
<br />
<br />6fn?
<br />
<br />
<br />Conditions contributing to the dealh but not related
<br />
<br />I'~}-o""",
<br />
<br />~6;;:1
<br />0 ACCIr;l~nt 0 Ufidel\?rrY\ll'"1od
<br />0 StJlclde 0 P\~ndll"\g
<br />0 HOflllClde Investigation
<br />
<br />[Ages 1 O-~41 Yes Nc'l Ye~
<br />260 DATE OF INJURY (Mo.. Day. Y'I 26c HOUR OF INJURY M-j26d DESCRI6E HOW INJURY DCCuRRED
<br />
<br />
<br />26e INJURY AT WORK ~hi~~~u~i~~,J~~.Y it;:g~r farm, slreet. factory ?6g, l.C)CAllON STREET OR R.F,Q, NO.
<br />Yes 0 No 0
<br />
<br />CITv OR TOwN
<br />
<br />
<br />27a OATE QF DEATH (Mo. Dr3y. Yr.}
<br />
<br />28a, OA Tf SIGNED {Mo, Day Yr J
<br />
<br />. -,. ,---,,~..__._-_.
<br />28b TlMt Of DEATH
<br />
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<br />o "
<br />(.l <:>
<br />
<br />2Bl:? Or' 1M oasIs 01 8-,:'amination ancl'or investigation, In my opinion oeMh OC(:\,Jrred;;:lt
<br />the time, dale and place <;ind dl,lf:! I() 1M cau~e(s) :;;!ated
<br />
<br />22
<br />
<br />2001
<br />
<br />28c, PRONOUNCED DEAD {Mo., Day, yo
<br />
<br />28d. PRONOUNCl::D DEAD
<br />
<br />{Mo.. Day. Yr.l
<br />
<br />27e. TIME OF DEATH
<br />
<br />27b
<br />
<br />-,
<br />
<br />12.1
<br />
<br />aM
<br />
<br />27d, To he best of my knowledge de.alh OCCurred a! the lime. date and place aM due to!M
<br />c.au~elsl staled.
<br />
<br />(51 natufe aM HIOI .... "-1'\..{ '-1 ^---' SI nature aM rIlle ...
<br />29 DID T06ACCO USE CON~UTE TO THE DEATH' JQ.a HAS ORGAN OR TiSSuE DONATION BEEN CONSIDERED'
<br />
<br />o yES !,Xl NO 0 UNKNOWN 0 yES fi1 NO
<br />
<br />31 NAM[ AND ADDRESS OF CERTIFIER {PHYSICIAN. CORONeR'S PHySICIAN OR COuNTY ATTORN[Y! rTyoe 0' P""IJ
<br />
<br />30 b WAS CONSENT GRANTED'
<br />DYES
<br />
<br />Anne K. Morse M.D.,
<br />
<br />729 N.
<br />
<br />cust~ Ave.'/Gr~d Is1and, NE
<br />/ I' /i/---
<br />" ,,' Jfl'~" t . ~l {( J& .it :t-l' ,
<br />f\J'\./.iI. Ii.......:...~ f-J. .~./ ,~: '.J,~"~,
<br />_.{j II
<br />
<br />68803
<br />
<br />J2,~t Q[GISTRAR
<br />
<br />F nATF Fit EO BY RFGISTRAR IMo
<br />
<br />I JUL
<br />.- .
<br />
<br />n,.~y Yr}
<br />
<br />2 7 2001
<br />
<br />STAT I::
<br />
<br />M
<br />
<br />(ffOllll
<br />
<br />M
<br />
<br />.JlI NO
<br />
<br />Lot Three (3), having a lakefront footage of 100 feet situated on the East side of the West portion
<br />of Kuester Lake and being a part of the East Half of the Southwest Quarter (E1/2SW1/4) In
<br />Section Thirteen (13), Township Eleven (11) North, Range Nine (9), West of the 6th P.M., Hall
<br />Co.unty~raska, commonly known as Kuester Lake #58, Hall Co.~_~~, Nebraska.
<br />
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