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<br />STATE OF NEBRASKA— DEPARTMENT Of HEALTH 00084 2
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH)/,.,/(/
<br />D EDENT -NAME FIRST MIDDLE LAST TSEX DATE Of DEATH fMo., Day, Yr.) - --
<br />I. Forrest LaV_ ern VanPelt I Male , lrla l9 1978
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<br />RACE -(e. While, BIacS. Am.rk.n ORIGIN)DESCENTIe —_ —: _ �-^ - —
<br />g,. g., ItDlion, Meei;* , AGE - -lep Rinhdmr _ _UNDER_I YEAR UNDER 1 DAY DATE OF BIRTH (Mo.. Day, YrJ
<br />Indian, efc.l /Spelifyl G•rmon. •k,) (Specify) (Y, .1 MOS. DAYS HOURS' MINI
<br />.. White Amer_ ican o 6a' 65 6b, 6c 7. ZTOVe 25, 1912_
<br />TTY AND STATE Of BIRTH IN amt in U.S A., CITIZEN Of WHAT COUNTRRY��M�- AgR1EO, NEYFR MARRIED, NAME OF SPOUSE (II rife, Sire maidrn name)
<br />nue —B.. Archer. Nebraska �g. USA j,oloowEld laixiedpe "ly' II ITorma �Ri7� °s VanPe1t
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<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION /Lire Lind e1 wed done d.v ,g m a 1 KIND Of BUSINESS OR INDUSTRY COUNTY OF DEATH
<br />01 'k .no Ii Fe, ..an d Ii
<br />r.-d)
<br />)a. - 16 —tots_ 0 erat4 n ' neer ''�13b. IA.. Hall
<br />_Various
<br />CITY. TOWN OR LOCATION OF DEATH INSIDE CITY LIMIIS HOSPITAL OR OTHER INSTITUTION - Name (1f nat in either. IF X051 01 INST Indian. DOA.
<br />(Specify r , or No) gi.e rueol and number! Outppli•nt /Em•. Rm Inpeti.nt ISpeady/
<br />, Island L.1. Yes ud. Lutheran Pleniorial Hospital I.. Emer nc Room
<br />RESIDENCE -STATE COUNTY
<br />CITY. [OWN OA LOCATION STREET AND NUMBER INSIDE CIiY LIMBS
<br />f Spacily Ye o. No)
<br />IS.. b 4-gkQ Lsb. Hal7L___
<br />15c Grand Island Isa. DLO W. 12th ,_IS.. Yes
<br />FATHER -NAME H i MIDDLE LAST MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />J sge yat_ Leola._ Leisure
<br />_
<br />AS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.f.D NO.. CITY 01 TOwN(SISIt7EL P)
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<br />rIUMM.
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<br />__ __ ___ i,9 i'irs_f __R__- W, 12th: Grand Island.Ne.
<br />CREMATION• RGMOVAL DATE (CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />13u=i&l N Island HE
<br />P�k(STREET
<br />IM SI
<br />8l10ENSEkO. 10('1 [fie FUNERASHOMEYrNAME AND ADDRESS Of 1f 0 NO., CITY 02 TOWN,
<br />VU/ L8b0l
<br />22 Livin.'stoxi- Sonuermar_u_,I_ 0� a.k;oen_. Grand Isl,_ndO,I7eV.L
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<br />T Me M. M q.ee tN...Pd•eth «.uN•d a lime daro ni piece o d dve ro 1n. On M• b «n of .amm,nvnun nd(e1 In pq N n • y •p-i- de•1h «a d at
<br />ame,.p) ear d. ,1 ` Z> - i th. t.m., deN a.d pl «. a +d dd' to 11.• — .1a) awud.
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<br />51
<br />11h�t a =�
<br />aH, fSi ne1•r• met idle) � �+
<br />—�. -- 7da (S,ga. ad f.r.l.
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<br />A SIGNED (hM., DYr.) HOUR Ci DE,tT DATE- fGLJE67i.MO Duy. Y. 1 H U AD A
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<br />v 2 3b 23c. � • RMi 12.b
<br />. . 24c M
<br />CO'
<br />E (PRONOUNCE DEAD (Mo.,Ooy. "•; PRONOUNCED DEAD (Hour) O PRONOUNCEDDEAD PRONOUNCED DEAD IHmur)
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<br />l a Ct 8 (n.
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<br />479d •� 7. M I2W
<br />NAME AND ADORE 5 C PIER !PHYSICIAN, CORONER'S PMYSICI NOR COUNTY ATTORNEY) (I ype ar Pl.nff —�
<br />Susan Dhillon, X. D., 180b Cleburn, Grand lsiand,-le. b8b01
<br />REGISTRAR • —`DATE
<br />RECEIVED BY REGISTRAR (Mo. Day, ra 1 {/�!
<br />P�2M.fS.w.mD� «��.L --
<br />�i. IMMEDIATE CAUSE LY AJSE PER LINE fOR (ol. Ib). AND (r l) I oibet[.en Wand damp.
<br />64
<br />- -bL "TO, OR AS A- -45EQUENCE Of: baw.n ..,aa and a.am
<br />Ibt
<br />DUE 10, OR AS A CONSEOUEN^_E Of: �„Nr.o16.1..•, en..t.nd deem
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<br />'tY�itli Sa`vl�,[ANi COt,plteONS ..a d.r �� rmnn.Avn wm.____
<br />^PART e ro d.ath bv1 .lu1.d PART In IE WAS AUTOPSY S CAS! t/rE1fl0 TO MEdCAt
<br />PREGNANCY IN fH IN r" F PAST 3 MO MONIHli I (Sy..•I> T.a P. Npl � FRAMIN[R D1 CD10NE1
<br />Sw,.l. >.r ar Net
<br />re, ii No L
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<br />At C•DENf, SuKtD(. XOwCtDI, UN «- /.T, QAit -q INIURI fMe.. our Y, 1 XOU! 0/ NaIUmY i DESCRIBE How WWII OCCULTED
<br />Of eENgING aWHSTIGAi�t (SP•adyl i
<br />'. ( :, «OY Tn .. Na; eaa•b..ld,n. .rt rspanp
<br />f•.....!. _......_�_______�.�.`s:.....___ -------- ___.__ _____------ ... ___.._. _308. :___.__�— ..__._._
<br />iiMEN ,T*115- COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />'STATE UDARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A -TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT-OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />;. IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
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<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued May 25, 1978
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