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6 <br />C rn CA <br />I _ a: <br />7 , <br />C'1 cn <br />n D �y <br />c I <br />T; <br />67'Q CD <br />� v <br />V� l <br />zc+ -nr <br />moon <br />Cr c C+ <br />i C+ Z <br />a c+ -1 <br />Inmmf <br />7C m m <br />fy n O O <br />• J. (+ <br />C+ C \� <br />� � 1 <br />? i1 <br />0-0 <br />"h C <br />m aN <br />O (A A <br />dSv <br />c+ <br />F-r O <br />N O � <br />iw -a -n <br />Q <br />m C+ <br />=y J• <br />O <br />c� a <br />te+ C+ A <br />v O <br />3 <br />c' < ' o <br />tT m CD <br />oT O <br />v <br />r> p <br />r >. <br />U-' c. <br />N Cn <br />LD c0 N .Z <br />cn <br />O <br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORB D FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTS SECT4 N,_WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />ANLEY_S.'GOOPER <br />7/14/2004 200500962 ASSISTANT SIAM AgGiftPOR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE$ YRTANCE AND &PPORT <br />VITAL STATISTICS -- 0 4 073 <br />0 0 <br />CERTIFICATE OF DEATH = - <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />Z SEX - - - <br />3. DATE OF DEATH (Month. Day. Year) <br />Arthur Daryl Hough <br />Male <br />June 30, 2004 <br />4. CITY AND STATE OF BIRTH 1/f not in U.S.A.. name country) <br />5a. AGE -Last 8inhday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH [Month. Day. Year/ <br />51p. MO& DAYS <br />5c. HOURS MINS. <br />(Ages 10 -541 Yes No <br />(Yrs.) <br />� Yes No <br />Council Bluffs, Iowa <br />81 i <br />OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />June 10, 1923 <br />7. SOCIAL SECURTIY NUMBER <br />Be. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER_: ❑ Nursing Home <br />506 -20 -3553 <br />7 Suicide ❑ Pending <br />7 Homicide Investigation <br />26e. INJURY AT WORK <br />Yes No <br />ER Outpatient ® Residence <br />Bb. FACILITY -Name /dnot institution, give street and numherl <br />2604 West 1st St. <br />❑ DOA ❑ Other(Specdvl <br />Sc. CITY. TOWN OR LOCATION OF DEATH <br />INSIDE CITY LIMITS <br />8d. U <br />Be. CCUNTY OF DEATH <br />Grand Island <br />Yee Ri ❑ <br />Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER llncluding Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2604 West 1st St. 68803 <br />Yee ® No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13, NAME OF SPOUSE (tl wife. give maiden name) <br />etc.) (Specify) <br />(Specify) <br />American <br />NEVER DIVORCED <br />Vera N. Cool <br />White <br />H? ` <br />RRI <br />CONSIDERED? <br />14a. USUAL OCCUPATION /Give kindot work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elementary or Secondary (0 -12) College 0 -4 or 5 -1 <br />of working iite, even d refired! <br />supervisor/Expeditor <br />New Holland Manufacturing <br />12th Grade <br />16. FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Darius Arthur Hou h <br />Faustina Maxine Daugherty <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes. no. or unk.) I (If yes. give war and dates of services) <br />Yes II 08/06/1943 -12 /22/194 <br />Vera Hough <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP) <br />2604 West 1st St., Grand Island, Nebraska 68803 <br />2 MBALMER- SIGNATURE B LICENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />4 � D-tu p xz #4-3 <br />® Burial ❑ Removal <br />July ' 2, 2004 <br />Grand Island City Cemetery <br />22a. FUNERAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston- Sondermann F.H. <br />❑Cremation ElDonatlon <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23, IMMEDIATE CAU TER ONLY E CAUSE PER LINE FOR lal. Ibl. AND (cp i Interval between onset and death <br />t <br />PART -t <br />I <br />k lal I <br />DUE TO, OR AS A CONSEQUENCE OF �- ( Interval be Mn onset and <br />death <br />rot <br />1 UUt 1U. VMAJAI.VrvJCVVCrvI.0 V7 <br />Ic) <br />I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III .IF FEMALE WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />II <br />(Ages 10 -541 Yes No <br />Ves F No <br />� Yes No <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. <br />OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />7 Accident r_1 Undetermined <br />7HOUR <br />M <br />7 Suicide ❑ Pending <br />7 Homicide Investigation <br />26e. INJURY AT WORK <br />Yes No <br />26f. PlALACE bull QF INJURY % t hp�r, farm. street factory <br />o Ce din etc. <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />27a. DATE OFF DEATH (Mo... Day. Yr.) <br />28a. DATE SIGNED (MO.. Day. Yr.) <br />28b TIME OF DEATH <br />aNi <br />i <br />27b. DATE SIGNED (Mo... Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD /Mo.. Day, Yr) <br />28d. PRONOUNCED DEAD (Hour( <br />. Eo <br />(/rl V ©�� T <br />�:7� M <br />J <br />. <br />= <br />M <br />27d. To the best of my knowled4e. death turned the Nme, dat d place and due to the <br />auhe b stated. <br />28e. On the basis of examination and -or investigation, in my opinion death occurred at <br />the time, date and place and due to the causes) stated. <br />ISi nature and Title) ► <br />(signature and Title) ► <br />29. 010 TO O USE CONTRIBUTE TO THE DEA <br />H? ` <br />30.a AS ORGAN OR TISSUE DONATION BEEN <br />CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ NO <br />UNKNOWN <br />A- ❑ YES <br />NO <br />❑ YES �N. <br />31 -MANX- AND ADDRESS OF CEHTIFItH FHYSK: IAN, UUHONtH S YHY5l(:IAN UH UUUN I Y A I I UHNtY) <br />