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WIEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />SYS'/EPA RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,T
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - w
<br />DATE OF ISSUANCE
<br />2/25/2004 20080999E '!"`
<br />LINCOLN, NEBRASKA HEAL *AHD
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALT14 AND
<br />VITAL STATIST kl
<br />CERTIFICATE OF DtAtWi f .
<br />y"
<br />k� l ��
<br />RT;;
<br />I; °d�946
<br />1. DECEDENT - NAME .FIRST MIDDLE LAST
<br />SEX
<br />5, DATE O, .. EAT" IManrn. Day. Year)
<br />Charles William Carr th
<br />Fa
<br />4. CITY AND STATE OF BIRTH Plindl In U.S -A.. name country/
<br />5a. AGE - Laat IB holey
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />v�
<br />MOS. DAYS
<br />M
<br />Dunning ,Nebraska
<br />"fe l 66 56.
<br />n
<br />7. -SOCIAL SECURTIY NUMBER
<br />B0. PLACE OF DEATH
<br />HOSPITAL. 1i Inpatient OTHER Nursing Home
<br />506 42 2601
<br />N
<br />El ER Outpatient �. Residence
<br />9Q FACILITY - Name /il not institution, give street and number)
<br />C
<br />❑,DOA Other(Specdy)
<br />9c. CITY, TOWN OR LOCATION OF DEATH
<br />V
<br />Bd, INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />` Omaha :
<br />Yes ® Nc ❑
<br />DoU l as
<br />m�
<br />96. COUNTY
<br />go. CITY, TOWN OR LOCATION
<br />®
<br />Be . INSIDE CI S
<br />Nebraska
<br />Hall
<br />Grand Island
<br />246 N• Darr 68803
<br />Yes F7 Ne
<br />IT 4CE - (e.g,, While. Black, American Indian.
<br />11, ANCESTRY (e.g.. Italian, Mexican, German, am)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (fl wile. give maldan name)
<br />ell:.) Specify)
<br />ite
<br />(Specify(
<br />American
<br />NEVER DIVORCED
<br />Lively
<br />------------------------
<br />14a. USUAL OCCUPATION /Give kind of ,,k done during mdar 714b.
<br />KIND OF BUSINESS INDUSTRY 115.
<br />M C)
<br />Elementary or faepndary (0 -12( College ,(1,4 or 5.1
<br />G
<br />of working Ne, even ifrenradl
<br />Driver
<br />l l uck�n g
<br />19. FATHER -NAME FIRST MIDDLE LAST 17,
<br />(�
<br />Clayton Charles Carruth
<br />g
<br />19, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT - NAME .
<br />(Yee, n0, or unk.) (II yes, give war and dates of services)
<br />es 8257 -11
<br />Sylvia Carruth
<br />Y
<br />191b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO„ CITY OR TOWN, STATE, ZIP)
<br />aD
<br />2p. EMB MER - SIGNATURE & LICENSE NO.
<br />rn
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY - NAME
<br />2 Burial Removal
<br />Febr. 13, 2004
<br />tibstLw 4 nari.al P&k Csretery
<br />FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation Donation
<br />Grand Island, Nebraska
<br />. FUNERAL HOME ADDRESS (STREET OR R.F.Q. NO.. CITY OR TOWN, STATE, ZIP(
<br />2929 S. Locust St. Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. (b), AND (c)I Interval between.,pnsal and death
<br />I
<br />PMT
<br />Il,.jPulseless Electrical Activity minutes
<br />I
<br />DUET , OR AS A 00NSEQUF4M OFD Interval behveein onset and dealh
<br />(b)Mitrai Stenosis years
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset ana death
<br />I
<br />I
<br />(c)OTHER
<br />SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />rn
<br />PART PREGNANCY
<br />1 Pulmonary ertention CHF
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />y yp (Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />�L
<br />o
<br />26c. HOUR OF INJURY
<br />�
<br />A
<br />M
<br />❑ Suicide ❑ Pending
<br />250, INJURY AT WORK
<br />261. PLACCE %INNJURV (tt hoPr, term. sveel. factory
<br />bbulldl
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes Nc
<br />F- A
<br />Cn
<br />27a. DATE OF DEATH /Ma. Day. Yr.)
<br />26a. DATE SIGNED (Mo.. Day. Ye)
<br />26b. TIME OF DEATH
<br />February.8,2004
<br />YY
<br />Sgi
<br />M
<br />o
<br />276. DATE SIGNED /Ma. Day. Yr.)
<br />x
<br />g �
<br />26c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /HOarJ
<br />�
<br />February 12,2004
<br />11:39am M
<br />4J
<br />$_�
<br />M
<br />Cil
<br />27d. To the beat 01 my knowled death attuned at the time, date and place and due to the
<br />280. On the basis of examination and/or Investigation, In my opinion (loam occurred at
<br />8 me time, date and place and due to the cauae(s) elated.
<br />10
<br />cause(sl slated.
<br />c4i
<br />,
<br />(Signature and 7it101 ► v d
<br />sl nature and title ►
<br />29. DID TOBACCO USE CONTRIBUTE TV THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION EN CONSIDERED?
<br />w
<br />v.,
<br />Lot
<br />4 and the
<br />South 6 feet of
<br />Lot S,
<br />in Stock 20, Packer
<br />and
<br />A � �
<br />to
<br />Barr's
<br />Second
<br />Addition to the
<br />city of
<br />Grand Island, Hall
<br />County,
<br />Nebraska.
<br />WIEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />SYS'/EPA RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,T
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - w
<br />DATE OF ISSUANCE
<br />2/25/2004 20080999E '!"`
<br />LINCOLN, NEBRASKA HEAL *AHD
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALT14 AND
<br />VITAL STATIST kl
<br />CERTIFICATE OF DtAtWi f .
<br />y"
<br />k� l ��
<br />RT;;
<br />I; °d�946
<br />1. DECEDENT - NAME .FIRST MIDDLE LAST
<br />SEX
<br />5, DATE O, .. EAT" IManrn. Day. Year)
<br />Charles William Carr th
<br />Fa
<br />4. CITY AND STATE OF BIRTH Plindl In U.S -A.. name country/
<br />5a. AGE - Laat IB holey
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6, DATE OF BIRT /Month. Day. Year)
<br />MOS. DAYS
<br />Sc. HOURS MINS.
<br />Dunning ,Nebraska
<br />"fe l 66 56.
<br />3 1938
<br />7. -SOCIAL SECURTIY NUMBER
<br />B0. PLACE OF DEATH
<br />HOSPITAL. 1i Inpatient OTHER Nursing Home
<br />506 42 2601
<br />El ER Outpatient �. Residence
<br />9Q FACILITY - Name /il not institution, give street and number)
<br />I Omaha VA Medical - Center
<br />❑,DOA Other(Specdy)
<br />9c. CITY, TOWN OR LOCATION OF DEATH
<br />V
<br />Bd, INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />` Omaha :
<br />Yes ® Nc ❑
<br />DoU l as
<br />9L WAIOENCE - STgYE
<br />96. COUNTY
<br />go. CITY, TOWN OR LOCATION
<br />Bd. STREET AND NUMBER jlncludirrgZip Coda)
<br />Be . INSIDE CI S
<br />Nebraska
<br />Hall
<br />Grand Island
<br />246 N• Darr 68803
<br />Yes F7 Ne
<br />IT 4CE - (e.g,, While. Black, American Indian.
<br />11, ANCESTRY (e.g.. Italian, Mexican, German, am)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (fl wile. give maldan name)
<br />ell:.) Specify)
<br />ite
<br />(Specify(
<br />American
<br />NEVER DIVORCED
<br />Lively
<br />------------------------
<br />14a. USUAL OCCUPATION /Give kind of ,,k done during mdar 714b.
<br />KIND OF BUSINESS INDUSTRY 115.
<br />EDUCATION ISpecily only highest grade completed(
<br />Elementary or faepndary (0 -12( College ,(1,4 or 5.1
<br />G
<br />of working Ne, even ifrenradl
<br />Driver
<br />l l uck�n g
<br />19. FATHER -NAME FIRST MIDDLE LAST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clayton Charles Carruth
<br />Stella Helen Rarnes
<br />19, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT - NAME .
<br />(Yee, n0, or unk.) (II yes, give war and dates of services)
<br />es 8257 -11
<br />Sylvia Carruth
<br />Y
<br />191b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO„ CITY OR TOWN, STATE, ZIP)
<br />246 N. Darr Grand island, NE 68803
<br />2p. EMB MER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY - NAME
<br />2 Burial Removal
<br />Febr. 13, 2004
<br />tibstLw 4 nari.al P&k Csretery
<br />FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation Donation
<br />Grand Island, Nebraska
<br />. FUNERAL HOME ADDRESS (STREET OR R.F.Q. NO.. CITY OR TOWN, STATE, ZIP(
<br />2929 S. Locust St. Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. (b), AND (c)I Interval between.,pnsal and death
<br />I
<br />PMT
<br />Il,.jPulseless Electrical Activity minutes
<br />I
<br />DUET , OR AS A 00NSEQUF4M OFD Interval behveein onset and dealh
<br />(b)Mitrai Stenosis years
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset ana death
<br />I
<br />I
<br />(c)OTHER
<br />SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />1 Pulmonary ertention CHF
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />y yp (Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />�L
<br />26b. DATE OF INJURY (Mo.. Day, Yr.)
<br />26c. HOUR OF INJURY
<br />260, DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined
<br />M
<br />❑ Suicide ❑ Pending
<br />250, INJURY AT WORK
<br />261. PLACCE %INNJURV (tt hoPr, term. sveel. factory
<br />bbulldl
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes Nc
<br />ofdNfac ry
<br />27a. DATE OF DEATH /Ma. Day. Yr.)
<br />26a. DATE SIGNED (Mo.. Day. Ye)
<br />26b. TIME OF DEATH
<br />February.8,2004
<br />YY
<br />Sgi
<br />M
<br />x
<br />276. DATE SIGNED /Ma. Day. Yr.)
<br />27c. TIME OF DEATH
<br />g �
<br />26c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /HOarJ
<br />�
<br />February 12,2004
<br />11:39am M
<br />4J
<br />$_�
<br />M
<br />27d. To the beat 01 my knowled death attuned at the time, date and place and due to the
<br />280. On the basis of examination and/or Investigation, In my opinion (loam occurred at
<br />8 me time, date and place and due to the cauae(s) elated.
<br />10
<br />cause(sl slated.
<br />c4i
<br />,
<br />(Signature and 7it101 ► v d
<br />sl nature and title ►
<br />29. DID TOBACCO USE CONTRIBUTE TV THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION EN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />0 YES [I NO " UNKNOWN
<br />[71 YES NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (type or Prinf)
<br />Stephanie Hansel MD, Omaha VA Medical Center 4
<br />32a- REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /Ma, Day Yr.)
<br />A � �
<br />FEB i 9M -
<br />cv m
<br />cv
<br />U
<br />0
<br />co
<br />C-0co.�
<br />CID C
<br />Co
<br />2
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<br />• -4
<br />0
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