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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SVS7E'M," CERTlRES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRo:oN~. WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA T1STlCs~ONiWIjlt!OS <br /> <br />:TEU.;::;:""'FOR ;~LO;~ 205 . -~ ~~i~~i<,~t. <br /> <br />JUL 2 6 1999 ~Nt;EY:s.-eO~:; <br />ASSmTANTs:f~T1Wf8 <br />LINCOLN, NEBRASKA HEAL TH AND ii#fiAN SERVICES sy'aiE.1j{ <br />STATE OF NEBRASKA- DEPARlMENT OF HFALTII AND HUMAN Sf;RVICES'Sl.lA,N~ SlJ!'!!ORT <br />VITAL STATISTICS .... . .. ...0 - - ._~- <br />CERTIFICATE OF DEATH'':;:~,:'~ __u <br /> <br />1, OE.:Ct:.DENT - NAME <br /> <br />FIRST <br /> <br />MlDOlE <br /> <br />LAST <br /> <br />< S~X <br /> <br />. ::i.~ OF DEATH (Month Day, Ye~rJ <br /> <br />David <br /> <br />Allen <br /> <br />Thompson <br /> <br />Male <br /> <br />July 17, 1999 <br /> <br />4. CITY AND STATE OF BIRTH flf~in USA" niJfflt;lcountry/ <br /> <br />Mullen, Nebraska <br /> <br />SA. AGE. Last 6irthdav <br />(VIS.) 67 <br /> <br />UNDER 1 VEAR <br />5b. MOS DAYS <br /> <br />UNDER 1 OA V <br />5e HOURS MINS <br /> <br />6. DATE OF BIRTH (Month. Day. Year! <br /> <br />November 24,1931 <br /> <br />505-40-6056 <br /> <br />6' PLACE OF DEATH <br />':i.gSPIT~!:. <br /> <br />[Xl <br />D <br />D <br /> <br />Inpatient OTHER 0 Nu(s,lng Home <br />ER Outpatient 0 ReSidence <br />DOA D OtMf{S/Jr8C,fvi <br /> <br />.. 7. SOCIAL S~CURTIY NUMBER <br /> <br />;j <br />] <br />'I 6b <br />J <br />'I <br />:) <br /> <br />FACILITY - Name <br /> <br />(If nor /nslltutIon. 911#'1 S"HI and numbllrJ <br /> <br />St. Francis Medical Center <br /> <br />American <br /> <br /> <br />STREET AND NUMBER IlncludlngZip CIX1cI <br /> <br />ge INSIDE CITY l,IMITS <br /> <br />= 6e CITY TOWN OR LOCATION OF DEATH <br /> <br />Grand Island <br /> <br /> <br />9a. RESIDENCE - STATE <br /> <br />COUNTY <br /> <br />ele;,) (SpeCify) . <br />Whlte <br /> <br />11. ANCESTRY ,o.g. <br />ISpec'fyl <br /> <br />3rd 68810 Yo, IKJ No D <br />13 NAME or: SPOUSE (If Wife. givs maiden name) <br /> <br />Nebraska <br /> <br />Hall <br /> <br />J) <br /> <br />'4a uSuAL OCCUPATION ,awe kind of work cJat'tf) Qutlng most <br />of working liftl tllltNlll relireal <br />Truck Driver <br /> <br />Betty C. Anderson <br /> <br />i 5 EDUCATION {SpeCify only highest grade c::ompletedl <br />E'emelr~or Secooaary (O.12l College fl-4 C115~1 <br /> <br />~ 16 FATH~R - NAM~ <br />.:I <br />11 <br />11 16 WAS O~CEAS~O EvER IN uS. ARMED FORCES? <br />Q'~s. no. or unk.) (II yes. give war a1dalEl~ ~ services) <br />Yes: K rean 4- 0-~2 2-5-54 <br /> <br />190 INFORMANT MAILING AOOR~SS ISTREET OR RFO NO <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />, 7 MOTHER <br /> <br />FIRST <br /> <br />MIDDL!:. <br /> <br />MAIDEN SuRNAME <br /> <br />Clifford <br /> <br />Grace <br /> <br />Kearns <br /> <br />Betty C. <br />CITY OR TOWN STATE. ZIPI <br /> <br />Thompson <br /> <br /> <br />AIda, Nebraska <br /> <br />68810 <br /> <br />210 METHOD OF DISPOSITiON 21b. DAT~ <br /> <br />21c:: CE=METERY OA CRE:MA10RY NAME <br /> <br />~ Burial D Flemovijl <br /> <br />Jul <br /> <br />20, 1999 <br /> <br />Arcadia Cemete <br /> <br />210 CEMET~RY OR CR~MATORY LOCATION <br /> <br />Cll Y OR TOWN <br /> <br />STAT~ <br /> <br />Apfel-Butler-Geddes D Cr.""""" D Oonaboo <br /> <br />22b FUN~RAL HOM~ AOORESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIPI <br /> <br />Arcadia. Nebraska <br /> <br />::: <br /> <br />Ibl <br />DuE TO. OR AS A CONS[OuENC~ OF <br /> <br /> <br />Interval oetween onset and deam <br /> <br />1123 West Second, <br /> <br />Grand <br /> <br />68801 <br /> <br />23. IMM~OIAT~ CAU~. <br />I PART <br />.. I lal ..../\A..-- <br />1:1 DUE TO. OR AS A CONSEOuENCE OF <br /> <br />'. <br />-J <br /> <br />Sy._-~ <br /> <br />Interval between onsel i;lnd deCilh <br /> <br />Inlerval belween onsel aM oeat/l <br /> <br />(el <br />PART OTHEA SIGNIFICANT CONDITIONS - Conditions contributing to the dElillh but not related <br /> <br />" <br /> <br />26. <br />0 Accldefl' 0 UflOl:l'lefmlned <br />0 SUicide 0 Pel1d'r'lg <br />0 HomicIde If'\\feSllga\lof"1 <br /> 27a <br /> <br />2Gb OA TE OF INJURY (Mo.. O.y. Y'.j 26c. HOUR OF INJURY <br /> <br /> <br />M <br />261. 6~~6u~i~~Ji:~Y ,f',;g;;t farm. SIf8e1. ractory <br /> <br />26g LOCATION <br /> <br />STREET OR A.F.D. NO. <br /> <br />CITy OR TOWN <br /> <br />STATE <br /> <br />2618' INJURY AT WORK <br />Yes 0 No D <br /> <br />ISI nature and Tltl8) .. <br />29 DID TOBACCO USE CONTRIBUT~ TO TH~ DEA T <br />D Y~S ~., <br /> <br /> <br />28a. DATE SIGNED (Mo Oay Yr J <br /> <br />280. TIME OF DEA TH <br /> <br />27b <br /> <br />J1>U <br />~I=>- <br />::;g~ <br />.!!~8 <br />~~u <br />U a <br /> <br />M <br /> <br />.-.. ~.~ <br />!lIU <br />. OJ <br />- '< >- <br />-~ u~g <br />.~ ~ ~ <br />.!I <br />~J <br /> <br />28e. PRONOUNCED D~AO IMo Day. y,./ <br /> <br />26<1. PRONOUNCED DEAD (Hou" <br /> <br />M <br /> <br />M <br /> <br />28e. On tile baSis of expmlnallon and'or inv&Sligation, in my OpinIon aealn occurred at <br />1M lime, date and place and aue to the c8usel.slstBted. <br /> <br />3O.b WAS CONSENT GRANTED' <br />D Y~S <br /> <br />[3-;-. <br /> <br />31. <br /> <br />Gordon J. Hrnicek <br /> <br />Grand Island, NE. <br /> <br />68803 <br /> <br />32a REGISTRAR <br /> <br />32b DA T~ FILEO BY R~GISTRAR (Mo.. O.y Y'.j <br /> <br />JUL 2 3 <br />