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<br />WHEN rIllS COPYCARR/ES THE't)U.~AL OF THE NEBRASKA HEALTH AND'HUM~N~E"VlCES
<br />SYSTE'A( "" CERTlFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALI1~_FR:EWlTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT!~~~;JMljICH IS'
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ~--,~~~ic.""'~~_)~
<br />
<br />DATE OF ISSUANCE ~=.s~::, . .)7.~~
<br />8/21/2003 200900727 :~ ~t: -_ O-...~t~E{Q"R
<br />AS~T!W1~~R
<br />LINCOLN, NEBRASKA HEALTHANR~~~~~M ,
<br />STAlE OF NEBRASKA- DEPARTMENT OF HEAL1lI AND HUMAN SBR:\t,I~~UPPORT
<br />VITAL STA11STICS~".O"oi'; ':.~;:; ~~o .,::."
<br />CERTIFICATE OF DEA m:~:;;::::;':o:; , .
<br />
<br />09183
<br />
<br />1. DECEDENT. NAME
<br />
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />Glenn
<br />
<br />Raymond
<br />
<br />Stueben
<br />
<br />Male
<br />
<br />2003
<br />
<br />
<br />27, 1935
<br />
<br />4, CITY AND STATE OF BIRTH (lfnatin U,S.A.. name coon/ry)
<br />
<br />UNDER' DAY
<br />5c, HOURS I MINS.
<br />,
<br />
<br />Grand Island, Nebraska
<br />7, SOCIAL SECURTIY NUMBER
<br />
<br />80. PLACE OF DEATH
<br />HOSPITAL; XJ Inpallent
<br />D EA'OUlpatlent
<br />o DOA
<br />
<br />OTHER; D Nursing Horne
<br /> D Residence
<br /> 0 Other (t."peCltyJ
<br />
<br />507-36-1838
<br />
<br />Ilb, FACILITY - Name
<br />
<br />(If not institution. give street am1 tJumOsr)
<br />
<br />
<br />St.
<br />
<br />Medical Center
<br />
<br />
<br />OCA
<br />
<br />GJ.-and Io:.ld!!U
<br />
<br />!la, RESIDENCE - STATE 9b. COUNTY
<br />
<br />ad, INSIDE'CITY UMITS
<br />,---,
<br />'T~S KJ NO
<br />
<br />Nebraska
<br />
<br />
<br />American
<br />"b, KIND OF BUSINESS INDUSTRY
<br />
<br />oute sales/BottI~n
<br />LAST 17. MOTHER
<br />
<br />Grand Isla
<br />ANC"STRY le.s" .'Ia"oo, Mexicen, German, ole)
<br />{SpoCIIy}
<br />
<br />10. ,RACE - {e.g.. White. SlaCk, Americ'an Jl1dian.
<br />ele,IISpocilyl
<br />White
<br />
<br />, 4A. USUAL OCCUPATION (Give kind of WfJI'k dene ""ling most
<br />af working IifB, 6I'ven if t~tlred)
<br />Truck Drive
<br />16. FATHER - NAME FIRST
<br />
<br />MIDDLE
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Arthur
<br />
<br />
<br />Gillham
<br />
<br />Ethel
<br />
<br />NMI
<br />
<br />Stueben
<br />
<br />NMI
<br />
<br />18, WAS DECEASED EVER IN .u,s, ARMED FORCES?
<br />(Ye~. no, Or I,In~1 .(If yes. give wa.r and dales of services)
<br />No
<br />19b. INFORMANT
<br />
<br />
<br />Delores Stueben
<br />ISTREET OR R.F.D. NO" CITY OR TOWN. STATE, ZIP)
<br />
<br />620 N.
<br />
<br />
<br />St.
<br />
<br />Grand Island
<br />210. METHOD OF DISPOSITION
<br />
<br />Nebraska
<br />21b. DATE
<br />
<br />2'e, CEMETERY OR CREMATORY. NAME
<br />
<br />[jeuriol D Remov,' Au .15,2003 Westlawn Memor' al
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />
<br />D CremaJion D Donation
<br />
<br />
<br />Kleine Funeral Ho
<br />m. FUNERAL HOME ADDRESS ISTREET OR R.F.D, NO" CITY OR TOWN, STATE. ZIP)
<br />
<br />
<br />~
<br />
<br />I~erval betw8e~ on..S8t and death
<br />
<br />'U l.. ~ ,<-.s
<br />
<br />Interval between Onset and death
<br />
<br />lei
<br />.p.
<br />M
<br />
<br />FI SIGNIFICANT cONomeNs . ~. . ttlonE. contribuli~Q to. the de~th blJ! not r~ated
<br />
<br />C~-f y ," ~--
<br />
<br />2Gb, DATE OF IN~URY (Me" o.y, Yr.) 2Be. HOUR OF IN~URY
<br />
<br />26..
<br />
<br />.,' ~
<br />
<br />o AccIdent 0 Und8t8rmin~
<br />o Suicide D Pending 26e, INJUAY AT WORK
<br />o Homicide InvMllgSifion Yes 0 NO 0
<br />23{ DATE OF"D~TH lMe.. o.y, Yr.)
<br />- \\- ",'3
<br />~~ '-J
<br />I ~ ~ y DATE S~D ~MO Oay h,}
<br />
<br />
<br />~ i 27d, To Iho boSI 01 my
<br />cause(s)s:lated,
<br />
<br />
<br />280. DATE SIGN EO (Mo" D8Y Yr.!
<br />
<br />28b. TIME OF DEATH
<br />
<br />!'~ i:;
<br />
<br />J",ii
<br />>-0
<br />",,>-
<br />~<<~
<br />"'~z
<br />BilizO
<br />o I:i ~
<br />f-8~
<br />
<br />M
<br />
<br />
<br />28e. PRONOUNCED DEAD (MO.. Day, Yr,}
<br />
<br />28d. PRONOUNCED DEAD (Hoor)
<br />
<br />M
<br />
<br />M
<br />
<br />288. On the basis of examination aM/Ot Investigation, in my opinion C1eath occurred at
<br />the time, dale and place and due 10 the cause!sl stated.
<br />
<br />~b WAS CONSENT GRANTED?
<br />D YES NO
<br />
<br />GrCVv(J IS/eu-li NGi &Jl{J3
<br />
<br />32b. DATE FILED BY REGISTRAR (Mo" D8Y. Yr.}
<br />AUG 2 0 2003
<br />
|