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Nr~ ~ WHEN THIS COPY G4RR/ES TF/E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAAi SFI~/CES SYSTEIYy IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI(dINAL RECO~ pN FitE~l[I777 --_ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECflOAI, UYf~iCH'~&. THE LEGAL DEPOSITORY FOR VITAL RECORDS. =~' = I,.~p DATE OF ISSUANCE _ ~_ '~!~U _~' - J111 ~ Q Z~ r~ p i~ • I~NI.E' C©9PER _` w- Y LI M dr O O ~7 O ~ ~r 1 ~ ASSISTAAI~`.STATE REGISTRAR •=' LINCOLN, NEBRASKA HEALTH AND HUMAIi-,*~a~RVIC~$ SY~EEhI _ - STATE OF NEBRASKA- DEPARTMENT OF k[EALTH AND HL7MAN SERVICES ~lANCE ANA 5UPF0$T VITAL STATISTICS ~ • ~__ __ p CERTIFICATE OF DEATH ~° • ~ _ ~ ~ 0 ~ ~ S 1 bFl'FDFNT . NgME FIF1S1 MIDDLE LAST 2. SEX 3. DATE OF DEATH /Malrh Day. Yaarl Baisel Clark Jr. Male July 7, 2002 4. CITY AND STATE OF BIRTH /d np(m USA.. name c°unNyl 5a. AGE -Last Birthday UNDER 1 YEAR UNDER / bAV 6. DATE OF BIRTH !M°n lh. bav. Veaq St. Paul, Nebraska ~ (Vrsl 69 Sb MDS , DAYS Sc. HOURS MINS [ 7anuary J, 1933 •J 7. SOCIAL SECURTIV NUMBED 9a. PLACE OF DEATH •~mm 506^28-9405 HOSPITAL. ^ InpaOern OTHER ^ Nursing Home Bb. FACILITY -Name /!l nor Insdmn~orr, give street and number) ^ ER OutpatiaN ~ Residence Home : 3120 W . 16th ^ DOA ^ Other lSpearvr -.-. 8c. GTV TOWN DR LOCATION OF DEATH Btl INSIpE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ~ N° ^ Hall 9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION gd. STREET AND NUMBER llncluding hp Cpdel 9o INSIDE CITY LIMITS Nebraska Hall Grand Island 3120 W. 16th 68803 Yes ® N° ^ _.. 10. RACE - le.g.. White, Black. Amencan Indian. 1 I. ANCESTRY le.g.. Italian. Mexican. German, 91c1 12. ®MARPoED ^ WIDOWED 13 NAME OF SPOUSE /!I wde. give maiden name/ etc.l lSpecdyl ISpecityl White NEVER American ^ pIVORCED Claudia Phelps MARRIED tea. USUAL OCCUPATION lGrve kindW work done during mas! 14b. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only mghest grade completed) o/workiMile, even it reriredl Railroad Shuttle Driver Armadillo Ez~press _ ___ Elements Se6pndary to-121 'College lt.aai•I ~~` 16. FATMER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Baisel Clark Sr. Dorothy Whitt 18. wA5 pECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME Ives. no. or unk. III yes. gwe war a dates I serviced Xes: ~ teen 1~1$~1951 1/6/1954 Claudia Clark IYD. INFVHMANI MHILINV AUUHI=yy ISIHtI:I UR H,h.U. NU., CIIY UH IUWN. SIAIL. LIP( 3120 W. 16th, Grand Island, NE. 68803 20. EMBALMER -SIG A7U 8 LICENSE N0. G 21 a. METHOD OF DISPOSITION 21 b. DATE 21c CEMETERY OR CREMATORY NAME ~,~/~ ~~~.~-~d~-~~/227_ ~ ®e°hal ^ Remuval July 11, 2002 Elmwood Cemetery 22a. FUNERAL HOIAE -NAME ~~ 27d. CEMETERY DR GRFMATDRV LOCATION CITY OR TOWN STATE Apfel-Butler-_-Geddes 1 ^crlxnallm ^Dona°°^ St. Paul, Nebraska 226. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second, 23. IMMEDIATE CAUSE PART I ,a, Natural DUE TO.OR AS A CONSEQUENCE OF Ibl DUE TO. OR AS A CONSEQUENCE OF. Grand Island, NE. 68801 (ENTER DNLV ONE CAUSE PER UNE FOR lal. causes Ic) OTHER SIGNIFICANT CONDITIONS - Cmditi°ns Contributing to the death but (rot related PART PART III IF FEMALE. WAS THERE A 29 AUTOPSY II PREGNANCY IN THE PAST 3 MQNTHS~ (Ages ID•541 Yes No Yes Nd 26a. 26b. DATE OF INJURY /MU.. bay. Yr.J 26c. HOUR OF INJURY 26d, pESCRIBE HOW INJURY UCCUHRED Ac~ideM ~ Undelermmed Smcide ~ Pending 2fie. INJURY qT WORK 261. PLACE QF INJURY - pt nomg, larm, d Ice building etc lSpeciry M sueel. fadtory 26g~ LOCATION STREET OR R.F.D. NO. , ^ ^ . / Homicide Investigation Yes No 27a. DATE OF DEATH /Mo.. bay. Ycl 28a. DATE SIGNED /Mo.. bay yrl z ~ • ~ ~ 274. DATE SIGNED /Mp.. Day Yr.J 27c TIME OF DEATH ~Ui ~ ~ g 28c PR . NOUNCED DEAD /M°.. Day, Yrl g~n M ry ' ~s ~s'~ ~J U.Iy ~, ~oo~ ~ = 27d. io the hest pl my knowledge. death occurred at the time. date and dace and due to me ~ ° 28e, On the basis of e>tammation a pr inv sti causelsl stated. ~ the time, dale and place an e t ause ISlgnature and TMe) - SI nature and Title - 29. pip TOBACCO USE CONTRIBUTE TO THE pEATH? 30.a HAS ORGAN OR TISSUE DDNAYION BEEN CONSIDERED? CO ^ VES ^ Np ~ UNKNOWN ^ VES ~ NO 31. NgME AND ADDRESS OF CERTIFIER IPHYSIGIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type a Prrnfl I Irnerval between onset ono dean unknown _ _ I interval berv+een onset and deem I I I Imerval between onset one dnw I 28. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONEH~ Ves No CITY OR TOWN STATE 28b TIME OF pEATH ~ : d~ BIr~,_ 2Bd. PRONOUNCED DEAD /Hnurl 1 ~ : 2 7 a.TT},, my.opirnon death occurred al NT GRANTED? ^ VES ~ NO Sgt D Qsterman, GTPD, 131 S Locust, Grand Island, NE 68$pl 32a~ REGISTRAR w 32b uHIrrlLruBrHewai~~lrnn.u~rr~~o~