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<br /> <br /> <br />DA TE OF ISSUANCE <br />OCT 2 8 2002 <br /> <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H <br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RE -' <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI= <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .ft:=i~ <br /> <br />.200804981 <br /> <br />ASSIS~. <br />LINCOLN, NEBRASKA HEAL TH AND H <br />_...--;;..:::.1..:...... ..:.1:..:.........._ _~...- ........... <br />STATE OF NEBRASKA. DEPARTMENT OF HEALTII AND HUMAN SERVI~~. .. ~.j:.-.~..-~.....-2T <br />VITAL STATISTICS C'""..C. ... ^" ~,,",--::f'\ <br />CERTIFICATEOFDEATH---"'.~~~- V <br /> <br />12111 <br /> <br />, DEtW~NT. NAM~ <br /> <br />LAST <br /> <br />2. SEX <br /> <br />3. DATE OF DEATH (Mumn. Day, Year) <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />JAMES <br /> <br />CUNPSTON <br /> <br />10-12-2002 <br /> <br />MALE <br /> <br />EUGENE <br /> <br /> <br />7-20-1936 <br /> <br /> <br />~ NUfsing Home <br /> <br />o ReSidence <br /> <br />o Olho' (Spec"" <br /> <br />6. DAT~ OF SIRTH ("""'/fl. Day. Yo.,' <br /> <br />4. CITY AND STATE OF SIRTH IH""'t. U.s.A.. "''''''''QUfl/ryJ <br /> <br />Sa. AGE. Las, SloMa, <br />IY".' 66 <br /> <br />UNDER 1 YEAR <br />5". MOS DAYS <br /> <br />UNDER' DAY <br />50. HOURS MINS <br /> <br />G()TIIENBURG, NEBRASKA <br /> <br />8a PLACE OF D~A TH <br /> <br />HO~P'~ 0 <br /> <br />o <br />o <br /> <br />DOA <br /> <br />7. SOCIAL SECURTIY NUM6~R <br /> <br />507-38-2564 <br /> <br />Inpatient OTHER <br /> <br />8". FACILITY. No"", <br /> <br />IN oot in.j;fu/lo<1. 91" .lfll6l o"q numI>oN) <br /> <br />ER O""'Olonl <br /> <br />NEBRASKA/WESTERN IOWA HCS -VA <br /> <br /> <br />Be. CITY. TOWN OR LOCATION OF DEATH <br /> <br />ad. INSIDE CITY LIMITS <br /> <br />GRAND ISLAND <br />sa:-RESloENCE. STATE <br /> <br />~~:';" <br /> <br /> <br />I!rrCIu<Iin9Z/PC_1 <br /> <br />NEBRASKA <br /> <br />6880 <br /> <br />Yo> fXl No 0 <br /> <br />III Wife ,Qiv~ maiden name} <br /> <br />10. RACE:. (e.g.. Wtlile, Blal:;k.. American Indian. 11, ANCESTRY le.g.. hali.,... Melllcan, German. atel <br /> <br />e'ellSoeellyl WHITE ISpec'lvl AM E R I CAN <br /> <br />'.0-:- U.SUAL OCCUPATION IG...klndol__tNriotg/fl()$1 <br />oI-"inrI IiI8. ._ d_1 <br />COOK U.S. <br />16.-FAhj~", . NAME FIRST f,1IDDlE LAST <br /> <br />MAIOEN SURNAME <br /> <br />(DEe) <br /> <br />FRANK <br /> <br />CLARA <br /> <br />CA: <br /> <br />18.. WAS DECEASED EVER IN U.S. ARf,1ED FORCES? <br /> <br />YES' '" "nk' III ~~:~97Ci~14-VIETNAM <br /> <br />19b. INFORMANT f,1AIUNG AOORESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STAT~. ZIP) <br /> <br /> <br />3rd St <br /> <br /> <br />NAME <br /> <br /># 1 0 7 1 IRJ auria' 0 RemovOI october 17, Ft. M:::Pherscn National Caret <br />21d CEMETERY OR CREMATORY LOCATION CITy OR TOWN STATE <br /> <br />o 00m0II0n 0 Coo.."," <br /> <br />Mi\XWEIL NEI!RASI@.. <br /> <br />ALL F7U'IHS FtJNEWU. Kl1E <br /> <br />221>. FUNERAl HOM~ ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP! <br /> <br />2929 S. LOCUST ST., <br />23. IMMEDlA TE CAUSE <br />PART <br />I 10' PNElJM)NIA <br />DUE TO.OR-AS A CONSEOUENCE OF' <br /> <br />GRAND ISLAND, NEBRASKA <br />IENTER ONl v ON~ CAUSE PER LINE FOR lal. Ib). AND (ell <br /> <br />68801 <br /> <br />Homicide <br /> <br />InvestigatiOn <br /> <br /> <br />Intfltval between onsel and aeatn <br /> <br />? nAY~ <br />InterVAl between ~ and cleath <br /> <br />(b, NEUTROPENIA <br />DU~ TO. OR AS A CONSEOUENCE.oI', <br /> <br />2 nAYS <br />Interval between onset and death <br /> <br />(el NON HODGKINS LYMPHOMA <br />PART OTHER SIGNIFICANT CONDITIONS.. Cond"ions ~tlUIing '" lI1e deo1h but "'" ,.101"" <br />" <br /> <br />268; <br /> <br />26b. DATE OF INJURY 11olo.. Oay. Yr.) 2lIC. HOUR OF INJURY <br /> <br />o AeclI:Senl 0 Undetermined <br />o Suicide 0 pending <br />o <br /> <br /> <br /> <br />26e. INJURV AT WORK <br />Yo.D NoD <br />270. DATE OF DEATH IMo.. Oay. Yr.} <br /> <br />280 DATE SIGNED (Mo. Day V,.I <br /> <br />2Bb. TIME OF DEATH <br /> <br />~iL <br />~ Jl 19 <br />. ~ <br />. <br /> <br />10-12-2002 <br />27b DATE SIGNED (Mo.. Oay. Vr.l <br /> <br />Eai::. <br />f!!i <br />~U <br />u ~ <br /> <br />28e. On the basis of examination and'or investigation. In my opinion dealh occurred at <br />the lime. date and place and due to the cause(s) stated. <br /> <br />M <br /> <br /> <br />2&: PRONOUNCED DEAD (Mo.. Day, Yr./ <br /> <br />28<1. PRONOUNCED DEAD IHow <br /> <br />10-15-02 <br /> <br />M <br /> <br />M <br /> <br />NO <br /> <br />3O.b WAS CONSENT GRANTED' <br />o YES IX] NO <br /> <br />RAMCHANDRA KAMATH <br />32a. 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