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St. Francs 9c. CITY. TOWN OR LOCATION OF DEATH 9d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island ^e8 9 No- Hall 9a. -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AwD NUMBER WA,edWZ17 Cade) 9e. INSIDE CITY LIMITS Nebraska Hall Grand _Island 3004 W. 10th St. 68803 Yes ® ❑ 10. RACE - (e.(I, White. Black. Amer(cen tndan 11. ANCESTRY (a g.. Ihd�. Newark Gemw% e1q 12 ®MARRIED. ❑ WIDOWED: 13. NAME OF.SPOUSE p wuie. 9W a1aldBn name) ob1(SpecrY) Patricia Masek White h NEVER Iris Scottish '1p USUAL OCCUPATION (Calve a;ndai awk dbrla aFainq ^ 14b. KIND OF BUSINESS INDUSTRY - 15. EDUCATION [Sped y on y trigheel grade rwmpbted) deor*67g Ai. sewn Mre&84 i2 Seoabary 10.12) CaMlga 110 a5-1 Ener Sul Z r r LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME 18. FATNER -NAME FRST MIDDLE _ Gerald McConnell Bett Lockwood 1a WAS DECEASED EVER IN U.S. ARMED FORCES? . 19a INFORMANT -NAME (Yes. M (r Marc) of Yelp and dabea of swvtcae) Patricia McConnell NO I 19b, INFORMANT MAILING ADDRESS (STREET OR;RF.D. NO-CITY OR TOWN, STATE ZIM . 3004 W. 10th St. Grand Island NE 68803 211- HOMER - SIGNATURE &t EENSE.t 21a METHM OF DISPOSMON 270.. DATE 21a CEMETERY OR CREMATORY -NAME � r�" , ® �, Oct 1, 2003 Lincoln Memorial 21 d. CEMETERY METY OR CREMATORY LOCATION GTY OR TOWN STATE 22a FUNERAL HOME - NAME ,., ___, ❑ "°"""°" D-d- 6800 South 14th Street Lincoln NE PART I Mal fit Cardiopulmonary arrest. Interval between awab and dean unknown ' Iroa vat between cra et and death Interval between onset and dean+ I I RED TO MFJ]K. t-i OTHER SIGNIFICANT CONORIO NS - Cortrrdne ocrrelbterrg b 1M death but not related PREGNI - PREGNANCY IF FEMALE WAS THERE A IN THE PAST 3 MONTHS? 24. AUTOPSY 25. pUNNNER SF OR CORONER ?. m = C (Ages 10-sm- Yes No Yes X Mn Yes 288. ci, 29c. HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED Ti y e� �'. ° c a M V� cn 2se. INJURY AT WORK 29f. P� (�• M^^. s �� 2% LOCATION STREET OR R.F.D. NO. CITY ORTOWN STATE c7 1..- t� 1 m O, 27a. DATE OF DEATH (M 0.. Dry. Yr./ C:D 29® DATE SIGNED (Ab. Day Yr) 280. TIME OF DEATH CJ'1 October 2, 2003 6:46 am M O Ss K y : 27b. DATE SIGNED' (Ab- Dry Yrl 27¢ TIME OF DEATH 3 M s § - - 2AL To the beat d MY kntoasad90, duo occurred at the Ilra, dabs and t» and doe b da i n mY Wow deam o=wed at ' tlft rnro. dabs and on cause(s) amYd. e b c H a 11 Co A t t GJ1 cn TOO WHEN TINS COPY CARRIES ?FE RAISED SEAL OF THE NEBRASKA HEALTH AND HMM SERA$ Cn CONSIDERED? / .b WAS CON RANTED? ® NO ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH � YES ® NO YES SYSTEjK fT CERTF WHICH IS HUMAN SERVICES SYSTEM, VITAL STATISTICS__ -DATE FINED BY REGISTRAR JU0.., Day. Yr.) REGISTRAR THE NEBRASKA HEALTH AND THE LEGAL DEPOSITORY FOR VITAL RECORDS �ztv%jANL_ErS_COW)t OF ISSUANCE DATE r200500892 10/7/2 0 03 ASS �ANrS HEALTH AND SAN SERRVTCEftY,4 LINCOLN, NEBRASKA STATE OF NE MWKA-DFPARiMM OF HEALTH AND HUMAN SEKV T 11182 VITAL STATIS= - = 03 CERTIFICATE OF DEATH LAST 2 SEX 3. DATE OF DEATH (M00 DRY. Yew/ 1. DECEDENT - NAME FIRST MIDDLE Jack A. McConnell Male Se 26 2003 Yeah 4. CRY AND STATE OF BIRTH /anol n U.S.A.. /YnN ootle@yi Sa AGE -.lffi MMdaY UNDER 1 YEAR UNDER 1 DAY & DATE OF BIRTH lMon1Y1. DRY. se ADS. DAYS xHOURSI MINS. (Vrs.1 I Jan 28 1953 50 Cedar Ra ids, Iowa. BL PLACE Or DEATH 7. 90CIAI. SECURRY NUMBER HOSPITAL -arena OTHER: � Nur-m Hare 484 -70 -5.802 0 ER'O aflabient Residence (IlndtewbYLft%9n 0100 A dnt/nbw) 9b. FACILITY -Name ooA Dew Medical Center E.R. St. Francs 9c. CITY. TOWN OR LOCATION OF DEATH 9d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island ^e8 9 No- Hall 9a. -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AwD NUMBER WA,edWZ17 Cade) 9e. INSIDE CITY LIMITS Nebraska Hall Grand _Island 3004 W. 10th St. 68803 Yes ® ❑ 10. RACE - (e.(I, White. Black. Amer(cen tndan 11. ANCESTRY (a g.. Ihd�. Newark Gemw% e1q 12 ®MARRIED. ❑ WIDOWED: 13. NAME OF.SPOUSE p wuie. 9W a1aldBn name) ob1(SpecrY) Patricia Masek White h NEVER Iris Scottish '1p USUAL OCCUPATION (Calve a;ndai awk dbrla aFainq ^ 14b. KIND OF BUSINESS INDUSTRY - 15. EDUCATION [Sped y on y trigheel grade rwmpbted) deor*67g Ai. sewn Mre&84 i2 Seoabary 10.12) CaMlga 110 a5-1 Ener Sul Z r r LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME 18. FATNER -NAME FRST MIDDLE _ Gerald McConnell Bett Lockwood 1a WAS DECEASED EVER IN U.S. ARMED FORCES? . 19a INFORMANT -NAME (Yes. M (r Marc) of Yelp and dabea of swvtcae) Patricia McConnell NO I 19b, INFORMANT MAILING ADDRESS (STREET OR;RF.D. NO-CITY OR TOWN, STATE ZIM . 3004 W. 10th St. Grand Island NE 68803 211- HOMER - SIGNATURE &t EENSE.t 21a METHM OF DISPOSMON 270.. DATE 21a CEMETERY OR CREMATORY -NAME � r�" , ® �, Oct 1, 2003 Lincoln Memorial 21 d. CEMETERY METY OR CREMATORY LOCATION GTY OR TOWN STATE 22a FUNERAL HOME - NAME ,., ___, ❑ "°"""°" D-d- 6800 South 14th Street Lincoln NE PART I Mal fit Cardiopulmonary arrest. Interval between awab and dean unknown ' Iroa vat between cra et and death Interval between onset and dean+ I I RED TO MFJ]K. t-i OTHER SIGNIFICANT CONORIO NS - Cortrrdne ocrrelbterrg b 1M death but not related PREGNI - PREGNANCY IF FEMALE WAS THERE A IN THE PAST 3 MONTHS? 24. AUTOPSY 25. pUNNNER SF OR CORONER ?. PART N (Ages 10-sm- Yes No Yes X Mn Yes 288. 28b. DATE OF INJURY ffAL Day. Yr.J 29c. HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED UndGIMMOed M A.I.11 Suicide pealing 2se. INJURY AT WORK 29f. P� (�• M^^. s �� 2% LOCATION STREET OR R.F.D. NO. CITY ORTOWN STATE Homicide kwestigabbn Yes E] No E 27a. DATE OF DEATH (M 0.. Dry. Yr./ 29® DATE SIGNED (Ab. Day Yr) 280. TIME OF DEATH October 2, 2003 6:46 am M Ss K y 2&_ PRONOUNCED DEAD. Aid. Day, Yr.) 29d. PRONOUNCED DEAD /Heal Sept 26 20 6:46 am M 27b. DATE SIGNED' (Ab- Dry Yrl 27¢ TIME OF DEATH 3 M s § - - 2AL To the beat d MY kntoasad90, duo occurred at the Ilra, dabs and t» and doe b da i n mY Wow deam o=wed at ' tlft rnro. dabs and on cause(s) amYd. e cause(s1 armed. H a 11 Co A t t TOO and Too 1 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? / .b WAS CON RANTED? ® NO YES _ � NO ® UNKNOWN � YES ® NO YES M. NAME AND ADDRESS OF CERT (PHVSIGAM, CARONER'S PHYSICIAN OR COUNTY ATTORNEYI !Type orPW Jerom E Janulewicz, Hall County Attorney, 231 S Locust, Grand Island, NE -DATE FINED BY REGISTRAR JU0.., Day. Yr.) REGISTRAR OCT = 6 2003 Lot Four (4), in Block Four (4) in Colonial Estates Second Subdivision, City of Grand Island, Hall County, Nebraska.