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<br />..,
<br />
<br />NW RF ~Q,ASKA- DEPAllTMENT OF HEAL lH AND HUMAN SEll VICES FINANCE AND SUPPORT
<br />2 0 0 7 U ::f b 1 v/ VITAL STA TISncs
<br />CERllFICA n~ OF DEATH
<br />
<br />298336
<br />
<br />, ' DECEDENT - NAME
<br />
<br />FlFlST
<br />
<br />"'DOL<
<br />
<br />LAST
<br />
<br />: 2 SEX
<br />
<br />3 DATE OF DEAll-I Mom,.., Oa\ YUt
<br />
<br />I
<br />I William
<br />
<br />_~ANOST"'TEoFeIAT~ ilff'lOlTlUSA ~~CQl,mlry
<br />
<br />Clyde
<br />
<br />Topham
<br />
<br />Male
<br />
<br />
<br />18,
<br />
<br />2001
<br />
<br />Sa AGE I...as1 BlrtMav
<br />
<br />.. Ft. Riley, Kansas
<br />. ..... 7 SOCIAL 5ECURTIY NUM6e:~
<br />
<br />.:-'1 508-68-0439
<br />"1_"'''.'__"__''_
<br />.] ao F~ClllTY Name
<br />~ NHS-Univ. of Nebraska Med.
<br />
<br />(y,!. I
<br />
<br />49
<br />
<br />:jNOER , yEAR
<br />'" MOS OAYS
<br />
<br />UNDE~ 1 OA y
<br />'" HOVRS "'NS
<br />
<br />}'e~f
<br />
<br />June 9,
<br />
<br />1951
<br />
<br />Sa PLACI: .,?F DEATH
<br />~OSPIT A~.
<br />
<br />[]
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<br />
<br />NlJr$'''Lj I-!o......~
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<br />Inwtlt!!nl
<br />
<br />Q.T_~EO
<br />
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<br />o
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<br />
<br />RE!SClt;'''Cf-
<br />
<br />/11 r'lor If'lStrfutIOf'. glv~ srrf!!t?r ~f1C flumoefl
<br />
<br />El=! OiJl'oa\lem
<br />
<br />Center
<br />
<br />)OA
<br />
<br />Qt....e. 5&='.,--'
<br />
<br />8e :iTy TOWN OR LOCA TlON OF OEATH
<br />
<br />_,,~..,.~~,...i.,.~__.~
<br />'ac IJ\lSI;)E: Cliy _IMlTS ~ Be COUNTY :)( DtA1H
<br />
<br />, Oma ha
<br />'---------
<br />9a RESIDENCE. 51 ATE 9t:l COUNTY I 9c CITY TOWN OR lOCATIO"-
<br />
<br />i Nebraska I Hall bnd Island
<br />
<br />10 i=lACE leg White Bla~~ A.1""l@r'GanlnQljil"', '11 ANCESTRY ,eg !lallar. Me~l;:an German elc:: . ~;, [] MARRIE(J
<br />o!It I '$oecrty, 'SO{"~ltv'
<br />White American ONEJER
<br />I ~_ MARRIFD
<br />140 KIND OF eUSINE.S5 !NDuST~y'
<br />
<br />v., [Xl -'0 0 '
<br />
<br />Douglas
<br />9c STREET AND NuM8=:;;; l~tuatngZlc c~10e6880 3 :-.'" :....SIDE: CITy 1..IJ..,o;I"1":-
<br />
<br />1124 Chantilly Ave. Ves [ij ~c L
<br />
<br />U wIDOWED . 3 NAME or: SPOuSE I' ~,I,: ~.e r"l,3,.],.r ~,3mt!,
<br />
<br />U~'VORC<O I Patty Otto
<br />....: 5 EDUCAtION Spec !", :)"11\, "'Ignes: g'~.?:_ :::~Ole~ec
<br />
<br />1':'Cl '.~SLJAL OCCUPATIOI'\; (i'lIe kmdof wor;, aone al,JrmQ m05~
<br />'II al wor_'ln9 life, even rf f€1fI'eG
<br />~ Universal Mechanic
<br />~~ATHER - NA"E FIRST
<br />.-..
<br />.,t
<br />!.!II lS
<br />
<br />M'DDLE
<br />
<br />Manufacturing
<br />
<br />To;~am C.OTHER
<br />
<br />119~ INFO~MANi - NA"AE
<br />
<br />EIE"I'T)€'''!1j', r iconoor,
<br />
<br />0.'2',
<br />
<br />COH~€'
<br />
<br />r:li=lSi
<br />
<br />"JI1::tDLE
<br />
<br />MArDE~ SuRNAME
<br />
<br />Clyde
<br />"AS DECeASEO EVER IN V S AR..m FORCES'
<br />
<br />Vernon
<br />
<br />Bonnie
<br />
<br />Van Hook
<br />
<br />
<br />If y"e!;l 9111e war and dates 01 services I
<br />
<br />MAIl,JNG ADDR~5S
<br />
<br />Patty Topham
<br />:STRl;ET OR R,F 0 NO CITY OR TOWN STAT~ ZIPI
<br />
<br />Grand Island, Nebraska 68803
<br />21a METHOD OF" DISPOSiTIO~ : 211) DATE
<br />
<br />;?lC CEMETERy OFt CRf:MAT'J~' "-lAME:
<br />
<br />I
<br />[}Q s....., 0 R.m",a' I Feb. 22 2001 PhilJ.J..J?s Cemetery
<br />Z1d C~ME:Te.RY OR CRI;.MATQRY L.OCAiION Uf" JF. TOWN STATE
<br />
<br />Kleine Funeral Home
<br />
<br />o C_ DOooa"".- I
<br />_~.I
<br />
<br />Phillips
<br />
<br />Nebraska
<br />
<br />220 .UN<RAL "0"< ADDR<SS
<br />
<br />,STRE<T OR RF.D. NO CiTy OA TOWN. STATE. liP)
<br />
<br />3213 W. North Front Street, Grand Island
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />23 '....mIAT< CAuSE
<br />PART
<br />,
<br />
<br />IENTER ONLY ONE CAuSE ~ER uNE ~.Oj;l'al.lbl. AND leI!
<br />
<br />lntefl/a' oetween onset ane :li7 "J .
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<br />la'
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<br />S {;.PT/(
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<br />SHOe;::.
<br />
<br />!II
<br />I~
<br />:J
<br /><.
<br />:.1
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<br />OUE TO. OR AS A CONSmVE><<:E OF
<br />
<br />Inle' ,,j ~n On$f.!l anc ClEatl-
<br />
<br />101
<br />DuE TO. OR AS A CONSEOUENCE 01'
<br />
<br />5" Pc N 1 kN f v<Aj
<br />
<br />0-1~/fI<IAL-
<br />
<br />If: fl II ONI"il r
<br />
<br />Inle'".:r, :!@rwe-enO/'lS@l ana .J€",r
<br />
<br />lei
<br />PART OtHER SIONIFICANT CONDITIONS - Conc!lflOf15 c:ontr1b\J\1ng 10 the death OUt not relatl;!Q
<br />
<br />"
<br />
<br />(1t':IZH05If
<br />
<br />o ACCident
<br />
<br />o
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<br />
<br />SWCIQ@
<br />
<br />o
<br />o
<br />
<br />1: 260 DATE OF INJURY IMD.. Oar y,.) I 26c l-4OuR OF INJU~Y
<br />UI'l\1@Ie-HT'lIne(j
<br />
<br />
<br />i PART III IF F!;MAl.E WAS THERE. A 24 AUTOPSY
<br />I' PAEGNANCY 'N T~E cAST, MONTHS" i
<br />
<br />" rAQe~ 10-54\ Yes n No 0 I Yes D No
<br />! :;?&j, DESCRIBE HOW INJuRy OCCuRRED
<br />I
<br />..
<br />
<br />2'J WAS ::t.5~ REF=E:FlREs T,:) MEDiCA~'~
<br />E.XAt....W'..E.c; OF. CORONEV ..
<br />Y", n No lY(
<br />
<br />26.
<br />
<br />PendIng
<br />
<br />- AI home farm street lador'y
<br />iScec"Yl
<br />
<br />12&j
<br />
<br />I
<br />
<br />LOCATION
<br />
<br />STREE"T OR R F 0 NO
<br />
<br />CITy '~ TOW~
<br />
<br />STATt:
<br />
<br />YOl$G} No'O
<br />127<1 OAT!:: OF DEATH (Me D~ 'fr j A .~
<br />_ ~: ../ / I ~'L 4..0~ / ~ v . ... '" ~ ':" /'IA.
<br />.. E< f-:-: l~ ." ~-,..r. c
<br />'1 ~ ~ 1270 DATE S'GN~D ~ a...r, ; 27< TI","-OF ~H '
<br />~ ! ~ ~ .... ". I. _ ..'~ '
<br />_-:: ~ ~8 ' /t(';J.' 7 J' ~ "It''tJ10,u'' J
<br />
<br />Hom,c;u;@
<br />
<br />Inv~~119allor'l
<br />
<br />
<br />28a DA Tt SIGNE.D -..,:iiL"';"'O;~'-~~- -.,'."',.~'~--
<br />
<br />! 280 TIME OF vEATr'
<br />i
<br />
<br />I ;,-~. ~
<br />I ~ 2 12& P~ONOUNCED D~AD Me Day y,
<br />I ~ ~: ~I
<br />.. E":;: I
<br />I := ~ 3 28@ Oil the ba.s,l!j of ellamm;:Jflor a"'~ O1ll"lveSllgattOn In m~ 00!1110n ~a.!. X:::lJCTl!'d al
<br />--' ~ JII. tt"'Ie luTI€' o.ale- ancl place ana dU€' 10 the Lausel!il !itated
<br />
<br />! 28d PRQNOL;~;..:L~ :}E~D
<br />I
<br />
<br />..
<br />
<br />11-I()ur
<br />
<br />
<br />..
<br />
<br />NO
<br />
<br />i 30 b WAS CONSENT GRANTED'
<br />I 0 y<S
<br />i
<br />
<br />~o
<br />
<br />"18'32$5 Nf6fA$IA Mf1:>I(A.... L~N1f.K'
<br />j 3~ DATE FILED By REGISTRAR !Mo Da.
<br />
<br />I f tB 2 7 ZOOl
<br />
<br />':MAII/:
<br />Nt b !!'(li
<br />J, ;.S(
<br />
<br />This certifies this document to be a true copy of an original record on file with Vital
<br />Statistics. Douglas County Health Department. (~ha. Nebraska. Certified copies must have
<br />a raised seal in the area to the left. Reproductions of this green certificate are not
<br />leqal copies.
<br />
<br />Date issued:
<br />
<br />fEB 2 1 20m
<br />
<br />Registrar I
<br />
<br />~i'eV~
<br />
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