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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />200803703
<br />
<br />DtCfDEN - NAME
<br />
<br />fllST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />M.
<br />
<br />Hall
<br />
<br />14b. Grand Island
<br />IESIDENCE - STATE COUNTY
<br />
<br />l'a.Nebraska 15b.
<br />fATHER-NAME .1
<br />
<br />If 1405'. 01 INSI. 1.<1"0'. 1>0",
<br />(hlpotient/I",.r. .m.. I"potie"t ($pfl('i'1}
<br />Medical Center 14.. Inpatient
<br />
<br />STREET AND NUMan INSIDE CITY LIMITS
<br />(5p.."I'.".' or No)
<br />Phoenix 15eres
<br />IRST MI L L'lST
<br />
<br />16~ Frank
<br />WAS DECEASED EVER IN U.S. ARMED fORCU?
<br />,..... no, 0' VIIII~) I (U '*" ,i.... lilfor 0"'- dQl'." a' ..,vire)
<br />...No
<br />
<br />BURIAL. Cte...o,iQn4 Remoyol DA
<br />
<br />19.Francis Clark, Husband
<br />CEMETERY OR CRUMTORY NAME
<br />
<br />Volk
<br />(snUf 01 1.1.0. NO.. CITY 01 fawN. SfAOf, 1"1
<br />
<br />Phoenix Grand I~8~~~ ~
<br />CITY OIllOWN STATE
<br />
<br />22Apfel-Butler-Geddesll23 W. 2nd, Grand Island, NE.68801
<br />DAn IGN 0 (Mo. Day, '1',.1 HOUR OF DEATH
<br />
<br />..!t
<br />l~a 240.
<br />liS,;. 'RONOUNCED DEAD
<br />l"l:l (Mo., Day, '1',.)
<br />M v:Z U..
<br />JZ::>
<br />D28
<br />>-0-
<br />vD
<br />
<br />2..b.
<br />'RONOUNCED DEAD (How)
<br />
<br />M
<br />
<br />J9J'~
<br />
<br />'n"rwol betw.." CM'" IlInd d~th
<br />
<br />4b.
<br />DUE TO, OR AS A CONSEQUENCE OF,
<br />
<br />III'I,*tvGl .......n on," Gild deoth
<br />
<br />(<I
<br />-~I4U SIGNifiCANT CONOlTlQNS - C...<I.,;o.. ,D....'b.,;.; to <I.alh b., .., ,.Ia""
<br />II
<br />
<br />30..
<br />
<br />
<br />,,,n Ill. " fEMALE, WU Tl4l1E " "UTOPS~.
<br />,UGNANCY IN Tl4E 'AST 3 MONTI4S? (Sp..lI, Y . ...~ al
<br />
<br />V.. 0 No ~ 28. . U
<br />DI:;CI"~ 140W IN)URY OCCUIIED
<br />
<br />
<br />'lCCIDtNT, SUICIDt, HOMICIDt, UNDtT, !lATE Of INjUn (....., Da" y,.J
<br />O. .tN/lINO INVlSTIO""ON. (5,....1,)
<br />
<br />300.
<br />INJun AT WO.l
<br />IS~;" r.. .r No'
<br />
<br />30d.
<br />
<br />sunT 01 ..f.D. Na.
<br />
<br />cln OR TOWN
<br />
<br />STAU
<br />
<br />:-. ',:..............,=~:===---,~~
<br />
<br />~
<br />
<br />~,
<br />
<br />..i'~~"THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />,,'\.. ~..6"i~~PEPAATMENT OF HEALTH. IT CERTIFIES THE ABOVE TO BE
<br />':\....,. A''l'ap(,~PY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />"", . ('-. ;~tpAS.~jOF HEALTH. BUREAU OF VITAL STATISTICS. WHICH
<br />0..,.;..) ..... 'IS GAL DEPOSITORY FOR VITAL RECORDS.
<br />
<br />..... r#'6?l.-
<br />ii llIC.. .' ll... BECK
<br />AS~lSTANT DIRECTOR OF HEALTH
<br />
<br />./
<br />i"
<br />/"
<br />"'- ,
<br />
<br />
<br />I ss ued Feb rua ry 27. 1984
<br />LINCOLN. NEBRASKA
<br />
<br />.,;;;; "
<br />
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