Laserfiche WebLink
<br />"" ~. <br /> <br />.... <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUM~~!I:~~WPES <br />SYS1E"M, fT CERTlRES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECC?~~WtF#. <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TlSTlCS~)t:~I$'j2o <br /> <br />;~:~;ORYFORWTALRECORDa ~/l~k:~'i~ <br />20080337 8 ASSISTAt~~'fl~fRi:3 B <br />LINCOLN, NEBRASKA HEALTH AND~UM~$~S.~VM~'j-,? <br />':'..,:,; ,.. . -._-_....,1:...,,;.'..:....-."""':":: <br />STATE OF NEBRASKA- DEPARTMENT OF HEALrn AND HUMAN SERVIC~~~~~~ <br />CERTI~~AS~~~~EA TH -"~O:k';:-:~ie~:..~:ff2 11 0 2 5 <br /> <br />Roca, Nebraska <br /> <br />5a AGE, Last Birthday <br />IY"'90 <br /> <br />UNDER 1 YEAR <br />5b MOS I DAYS <br />I <br /> <br /> <br />Male <br /> <br />September 19, 2002 <br /> <br />,. DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />? SEX <br /> <br />3: DATE OF DEATH IMQnfh, Dav. Year} <br /> <br />James <br /> <br />Clark <br /> <br />Haile <br /> <br />4. CITY AND STATE OF BIRTH (If not in U.S.A.. flame COI.mlry) <br /> <br />6. DAlE OF= BIRTH IManth. Day Year} <br /> <br />.. <br />~ TSOC-iAl SECURTIY NUMBE~ <br /> <br />September 28, <br /> <br />1911 <br /> <br />IIf not Institution. give street ana number) <br /> <br />8a. PLACE OF DEATH <br />HOSPITAL D <br />D <br />D <br /> <br />Inpatient <br /> <br />OTHER [K] NurSing Home <br /> D ReSidence <br /> D Olner (Soecd\lJ <br /> <br />. <br />1 <br />~ 8" <br />. <br />1 <br /> <br />506-09-6200 <br /> <br />F=AClI..rTY - Name <br /> <br />F,R Outpal'iEtnl <br /> <br />Beverly Health Care/Lakeview <br /> <br />DOA <br /> <br />American <br /> <br /> <br />Hall <br /> <br />8c CITY TOWN OR LOCATION OF DEATH <br /> <br />&:I IN SlOE CITY liMITS <br /> <br />COUNTY OF DEATH <br /> <br />Grand Island <br /> <br />Nebraska <br /> <br /> <br />STREET ANO NUMBER flnclildfng Zip Code' <br /> <br />ge INSIDE CITY LIMITS <br /> <br />Sa. RESIOENCE. 5T A TE <br /> <br />10. FlACE - le.g.. While. Slack. American Indian <br />e'C.llspet:rh i t e <br /> <br />11. ANCESTRY re.g Italian, MeXican, German, elcl <br />(Spec'fyl <br /> <br />Yes D No [] <br />13 NAME OF SPOUSE IIf wife. qlv8 maiden name} <br /> <br />Ruby C. Knod <br /> <br />_ lola. USUAL OCCUPA liON IGlve kind of work done dlJnng most <br />'J 01 workmg Nf8. even if retired) <br />~ Owner/Operator <br /> <br />i 16. FATHER - NAME FIRST <br /> <br />Haile <br /> <br />EDUCATION (SpeCIfy only hlgnest gracle completed) <br />nta~or SecOndary 10,12) College 11.4 nr ~:]~I <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />: <br /> <br />Stuart <br /> <br />Grant <br /> <br />Nellie <br /> <br />Grace <br /> <br />Clark <br /> <br />t <br />- 16. WAS DECEASED F.VER IN US ARMFD fORCES? <br />;;;;; {Yes. flO. Or unk,) (II yes. give waf and oates of servicesl <br />No <br /> <br />NAME <br /> <br />"i9bINFORMANT <br /> <br />MAILING ADDRESS <br /> <br />Ruby C. Haile <br />ISTREET OR R.fD NO., CITY OR TOWN STATE. ZIPI <br /> <br />121 Leisure Lake Drive, <br /> <br />Doniphan, NE. <br />21 a METHOD OF DISPOSITION <br /> <br />68832 <br /> <br />20. EMBALMER - SIGNA TURE & LICENSE NO <br /> <br />yu- ). Wu.J.~ ftn z. 7 <br /> <br />:?1h. DATE <br /> <br />21c CE:MElERY O~'CR~MAl'OHy-- NAME <br /> <br />~BLlrial <br /> <br />D Remo'.' Sept. 23, 2002 Cedar View Cemetery <br />~ld CEMETERY OR CREMATORY LOCATION CITy OR TOWN STATE <br /> <br />220. FUNERAL HOME. NAME <br /> <br />Apfel-Butler-Geddes <br /> <br />D Cremation D OonallOfl <br /> <br />Doniphan. Nebraska <br /> <br />22t> FUNERAL HOME ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br /> <br />1123 West Second, <br /> <br />Grand Island, Nebraska <br /> <br />68801 <br /> <br />26. <br /> <br /><6" DATE OF INJURY (Mo.. Day. Yr.) 26e HOUR OF INJURY <br /> <br /> <br />IntE/~a; i)8i'-.,. 0":1681 ana oealh <br /> <br />. <br />II <br />J <br />.. <br />i- <br /> <br />23 IMMEDIATE CAUSE <br />PART <br /> <br />I I., Cirrhosis of the liver <br /> <br />DuE TO, OR AS A CONSEOUENCE OF <br /> <br />IENTER ONLY ONE CAUSE PER LINE FOR '" Ibl. AND lell <br /> <br />Intefval between onset In(lI1p.,,U' <br /> <br />Ibl Asci tes <br />DUE TO, OR AS A CONSEQUENCE OF <br /> <br />Inlervall:>elWeen onsel aM dealh <br /> <br />lei <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but no1 related <br /> <br />" <br /> <br />o <br />o <br />o <br /> <br />Accident 0 Undetermined <br />SUlcld~ 0 Pending <br /> <br />HO.."ICil19 <br /> <br />InveslIgaMfl <br /> <br />26e INJURY A" WORK <br />Ye, D No D <br /> <br /> <br /> <br />27a. .pATE OF DEATH (Ma.. Day. Yr.) <br /> <br />28.a. DArE SIGNED (Mo.. Day. Yu <br /> <br />28b TIME OF DEATH <br /> <br />September 19, <br />27b. DATE SIGNED fMo. Day. Y'I <br /> <br />2002 <br /> <br />M <br /> <br />27d. To 1M best of my knowledge. d~ <br />... ca.l.Jse(s) 51",led, I <br /> <br />r (SI9na~e_and Tillel .. /. <br />29 DID TOBACCO USE CON~ Td-'I'i <br /> <br />DYES l!1 NO <br /> <br /> <br />TIME OF DEA TH <br /> <br />28c PRONOUNCED DEAD (Mo" Day, Yr.) <br /> <br />28c1. PRONQUNCr::.lJ bEAD {Hl)Url <br /> <br />::: Ii ~ <br />. ~ ~ <br />- '!~;lo- <br />-= .3 ~i5 <br />-=n <br />i ~ ~ <br />J <br /> <br />9/24/02 <br /> <br />M <br /> <br />288. On lhe basl$ of examination aM or jnll@stigalion. in my opinion dealll occurred at <br />the lime. date and place and due to 1M causelSj stated. <br />l S nature and Tillel .. <br />ONSIDERED? <br /> <br />JOb WAS CONSENT GRANTED' <br /> <br />DYES <br /> <br />~O <br /> <br />31 <br /> <br />William J. Lawton <br /> <br />Ave. , <br /> <br />Grand Island, NE. <br /> <br />68803 <br /> <br />32. REGISTRAR <br /> <br />32b DATE Fll.l;O BY REGISTRAR (Ma.. Day. Yr) <br /> <br />SEP 3 0 2002 <br />