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200905269 • ' - • oYHEN THVS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSlE'A!~ (T CERTP:IES THE BELOW TO BE A TRUE COPY OF TIE ORIGINAL RECORQ OJV FILE WITH TTIE NEGRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STIC$ S~T;y~1-G_ H IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - ~ "- DATE OF ISSUANCE ~ - 1~• ~- - - ~I ~ANLEYS. COOPF.~E7-... 10/1 x'/20 0 3 2 O Q s Q "~ $ g 0 ass~~'dlv~TS~a~rff®srl~- LINCOLN, NEBRASKA HEALTH AND Ht]MA_N SER'VICEg~Sx~61 :; STATE OF NEBRASKA- AEPARTME-iT T OF HEALTH AND HUMAN' SEIbYICE$ F~k~ J ?- ~KNQSUPF[3RT VITAL $TATLSTICS _ ~- O CERTIFICATE OF DEATH - - 1, DECEDENT -NAME FIRST MIppLE LAST 2. SAX 3-~ DATE OF pEATH /Month. qay. VBarJ Margaret J. Halpin Female '' .October 1, 2003 4, CITY AND STATE OF BIRTH 111 not in USA.. name counmyl 5a. AGE - La61 Slnhday UNDER 1 YEAR UNDER 1 DAV 5. GATE DF 81RTH lMdnth, qay. Veer/ _ Greeley, Nebraska Iris.l 72 56. MOS. I pAYS 5c. HOURS' MINS, July 22, 1931 a 7. SOCIAL SECURTIY NUMBER 8a. PLACE DF pEAYH I~ HOSPITAL: ^ Inpatient OTHERS ~ Nur6mg Home ~ 505-58-0598 ~ --- 8b. FACILITY -Name /lI rtol insalufidn, give Street and number) ^ ER Outpatient ^ Resleenca I~ St. Francis Skilled Care ^ DDA ^ omer/specdv, Sc. CITY. TOWN DR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 8e. COUNTY OF pEATH Grand Island „ _ ,. u ~ i i _~_-. ~--- --- ~ , . 9a. RESIDENCE -STATE 9p. COUNTY 9c, CITY, TpWN QR LOCATION 9d. STREET AND NUMBER /Including Z/p gode! 9e INSIDE CITY 41MITS Nebraska Hall Grand Island 105 W. 20th St. 6$801 Yes ® Ntl ^ 10. RACE - (e.g., White. Black. American Itaian. 11. ANCESTRY le.g.. Italian. Mexican, German, etcl 12. ®MARRIED ^ WIDOWED 13. NAME OF SPOUSE Ill woe, give maiden name) gtc.115pecity~Tklite WIl (Specilyar •'Irish NEVER DIVORCED Stephen M ~ Halpin MARRI ; 14a. USUAL OCCUPATION /Give kind o! work dOnp during mns( 146. KIND OF BUSINESS INDUSTRY ~ 15. EDUCATION (Spetliry only highest grade completed) p/working l/19. even it reNredl e /Ma O G e Ma ket ,Elementary or Secondary 10-121. College 11-4 dr 5-I' 12 0 wn r ne er roc r r r, 15, FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME ~ John Harrahill Mary Maloney ~ 18. WAS DECEASED EVER IN U.S. ARMED FgRCES? 19a. INFORMANT•NAME IV o. ar unk.l Ilt yes. giv nd dates of servlcesl ~Io ~"~`[~ Stephen M. Halpin 19b. INFORMANT MAI ING ADDRESS ISTREET OR R.F.D. NO:, CITY OR TQWN. STATE. zlPl 105 W. 20th St. Grand Island, Nebraska .6$$01 20. EMBALMER -SIGNATURE & LICENSE NO. 21 a. MBTHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME vS~Lg- ~ ~ X^ 9unal ^ Remd.al Oct . 3 , 2003 Westlawn Memorial Park 22a. FUNERAL HOME -NAM 21 d, CEMETERY OR CREMATORY LOCATION CIYV OP TOWN STATE Curran Funeral Cha el ^ Cremation ^ Donation 3$26 W. Stolle Park Rd. G. I . NE 68 + 226. FUNERAL HOME ADDRESS I5TREET OR R.F.D. NO.. CITY OR TOWN . STATE. ZIPI 3005 South Locust St. IMMEDIATE CAUSE PART ~^ IaJ 771' DUE TO, OR AS A GONSEOUENCE Grand Island, Nebraska 68$01 IE ER ONLY ONE CAUSE PER LINE FOP Isl. Ibl, AND Icll I Interval between onset and death f3 I Interval 6etwee/y~set and death y + I AS mrervai cenveen onsar anc ceam Ic1 I OTHER SIGNIFICANT CONpITIONS -Conditions conmi6udng to the death but not related PART III IF FEMALE. WAS THERE q 24 AUTOPSY 25. WAS GASE REFERRED TO MEDICAL PART II PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Age51p-54) Yes Ntl Ye6 NO ~ Yes NO 28a. RBb. DATE OF INJURY /MO.. Day. Yr.) 25c. HOUR OF INJURY 26d. DESCRIBE HOW IN~JRV OCCURREp Accident ~ Undetermined M Suicide ~ Pending 26e. INJURY AT WORK ~ pp qq 1m~g 261. office ~ulding~etcV IS~IryI ,farm. street. Iactory / 28g. LOCATION STREET qR R.F.D. Nq. CITY OR TOWN STATE Homicide Investigation Ves ^ No ^ 2~. DATE DF pEA7H /MO.. Day. Yr./ ~ 2Ba. DATE SIGNED /Mo.. Day. YrJ 25b. TIME OF DEATH October 1 ~ 2003 ~ ~-a = a M d DATE SIGNED M D Y l TIME OF DEATH ~ C 28 PRONOUNCED DEAD /M D Y l PRONOUNCED DEAD /HOurl 28d ~ }s T . / ay. c d.. . ~ ~ c, o.. ay, c . ~~~ October 14,2003 8:50am M ~~~~ M th x rred a ti To the best of m wle e data and place and due Id the ~ ~ c~ In my opinion death occurred at On the ba6i6 dl eXemination anWdr Inve6ligatltln 28e I . y g . 9.¢ ~ ~ K , . th ti d t d l d d t th t t d l f cau6elsl stated. ' f e me, a e an p ace an ue o e cause sl s a e . ISM nature antl Title) - V`~--~ Si nature and Title DID TpBACCO USE CONTRIBUTE T T DEATH? ~.a HAS ORGAN OR TISSUE OONAYION BE EN CONSIDERED? 3 b wA5 CONSENT GRANTED? ~ ^ YES NO UNKNOWN .^ VES NO ^ YES !O 37. NAME AND ADDRESS OF CERTIFIER (P SICIAN, CORONER'S PHYSICIAN OR COUNTY gTTORNEVI /Type pr Priory Ryan D. Crouch M.D. 800 Alpha St. Grand I land, NE 68803' 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO., qay Yc/ ocT ~ s Zao~ U