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_ WMEI~f THl3 COPY CA/~ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND WOMAN SE'RIIICES
<br />SYSTEM, !!CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RFC_L~~!R'W~TN
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STl~3E~€I~~H/CH`/S
<br />THE LEGAL pEPOSITORY FDR VITAL RECORDS. _ ~ ~ ~ ,
<br />DATE O•= ISSUANCE ~ N•
<br />4~27~2004 +G~~ 9V ~ 2 V ~ ASS/SfiAN~t~k._-~~Pdl09R ,
<br />LINCOLN, NEBRASKA ~ HEALTH ANA HF~A1(AN`SERt7-CE;~?~Y;~1"~d41
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERSrlC~S.FIDI -
<br />- ~B'~RT
<br />VITAL STATISTIGS _ ryry G
<br />CERTIFICATE OF DEATH ~ --:.. = ~ 4 U ~ 6
<br />1. DECEDENT • NAME FIRST MIDDLE LASY 2. SEX 3. DATE OF DEATW /MVnrh, pay, year/
<br />Gerald Laverne Graves Male March 20, 2004
<br />4. CIYV ArJp STATE OF BIRTH Ill norm US.A.. name cpuneyJ 5a. AGE - La6t Bidnday. UNDER 1 YEAR UNDER 1 DAY B. DATE OF 81RTH /Month. pay. Year/
<br />
<br />Nance County, Nebraska ,Yrs.l
<br />79 56. MOS. GAYS
<br />I 5C. HOURS' MINS.
<br />December 18, 1924
<br />7. SOCIAL SECURTIY NUMBER Bd. PLACE OF DEATH
<br />
<br />506-20-4732 HOSPITAL: Inpatient OTHER: Nursing Hame
<br />_ ^
<br />9b. FACILITY -Name ///nor Insrduripn, give sheer and number/ ^ ER Outpatient ® Residence
<br />Home: ~~23 St. James Place ^ DOA ~ Other /SpeuN/
<br />9c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 8e. COUNTY OF DEATH '
<br />Grand Island - _ . _ -'Yea ~ Na ~ -- Hall
<br />9a. RESIDENCE -STATE 9b. COUNTY 9c, CITY, TOWN OR LOCATION 9d. STREET AND NUMBER /In0/ud/ng Zip Codel 9e. INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 4623 St. James Place68803 Yea No ^
<br />10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le.g.. Italian, Mexican, German, etc/ 12. ®MARRIED ^ WIDOWED 73. NAME OF SPOUSE /I/wile. give maiden name)
<br />etc.llSpecityl (5pecityl NEVER DIVORCED
<br />White Welsh/German MAR Ruby Garton
<br />-- - _..
<br />14a. USUAL OCCUPATION /Give kind of work donB during most 146. KINq OF BUSINESS WDUSTRY 15. EDUCATION ISpecily only highest grade completed/
<br />pl working 1//e, even i/retired/ Elementary }fir Secondary 10-12) College I1.4 or 5•I
<br />Engineer Northwestern Bell Telephon 1[,
<br />16, FATHER -NAME FIRST MIppLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clyde J. Graves Gwendolyn Thomas
<br />18, WAS DECEASED EVER IN U.S. ARMED
<br />FORCES? 1ga. INFORMANT-NAME
<br />p
<br />,X~~.runk.l I IZ~6.g5~13/19431Cee112/14/1945 Ruby Graves
<br />1 ao. IrvruMMAN I MAILING gDUNLSS IS 1'Htt I UN N. F, U. NO., CITY qR TOWN. STATE. ZIP(
<br />~~23 St. James Place, Grand Island, NE. 6$$03
<br />20. EMBALMER -SIGNATURE & LICENSE N0. 21 a, METHOD OF OI5POSITION 21 b. DATE 21 c. CEMETERY OR GREMATORV ~ NAME
<br />.>r1f /3.7r~
<br />• ~~ ©Burial ^Removal March 23, 200 Westlawn Memorial Park
<br />~ 22d. FUNERAL HOME -NAME
<br />Apfel-Butler--Geddes ^crematWn ^Dpnanvn
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />imrvicuw I r ~qusc
<br />PART / ~
<br />I ( _,•
<br />DVE 70 OR AS A CONSEQUENCE OF
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Grand Tsland, Nebraska
<br />(ENTER ONLY ONE CAUSE PER LINE FOR lab 161,
<br />I Interval 6ehveen onset and death
<br />I
<br />r ~ v ~ i mrervai oerween onset ana oeam
<br />t, I
<br />Ibl I
<br />DUE TO, OR AS A CgNSEpUENCE qF: I Interval between onset and death
<br />I
<br />Icl ~
<br />OTHER SIGNIFICANT CONDITIONS -Conditions comributing b the death bIX not related
<br />PART PART III IF FEMALE. WAS THERE A 2a. AUTOPSY 25. WAS CASE REFERREp TO MEDICAL
<br />
<br />II PREGNANCY IN THE PAST 3 MDNTM57 EXAMINER OR CORONER?
<br /> (Ages 10.541 Yea No Vey No ~ Ves No ~ ~~ ~~
<br />28a. 286. DATE OF INJURY /Mp.. Day. Vc) 280. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ~~'
<br />Accident ~ Undetermined
<br /> M
<br />Suicide ~ Pending 26e, INJURY AT WORK 28f. PACE (iF INJURY - At home. /arm. 6lreel, lavtory
<br />o ce bw ding, etc. l5peciry) 2Sg. LOCATION STREET OR R.F.D. NO. CITY OR TOWN $TAYE
<br />Homicide Investigation ^ ^
<br />Yea No '-
<br /> 27a. DATE OF DEATH Into.. pay. Y//
<br />~?
<br />J 28a. DATE SIGNEq /MO., pay. Yr1 286. TI EpF DEAYH
<br />s s /
<br />~I ?. ;;~ ~ C) ~ 1
<br />~ S ~' M
<br />} 27b, pgTE SIGNED /Mo.. Oa :
<br />Ycl 27v. TIME OF DEATH
<br />n ~ ~ 28c. PRQNOUNCED DEAD Into., pay, Yr,/ 28d. PRONgUNCED DEAD /Hour/
<br /> (fi
<br />,
<br />~ g
<br />,° 8~ 27d. To the best of my knowledge. death occurred at t I
<br />date~rld place. nd due to the v 288, On the basis of ekaminadpn and~or Inveatlgatlon, in my opinion death occurred at
<br /> Causelsl stated, f f
<br />~~~ /
<br />/ u b the time, data arW place and due to the causes) stated.
<br /> ISi nature and Tigel ~ ~
<br />' / ~ Si nature and TIIte
<br />. 29. DID TO
<br />BA
<br />CCO USE CONTRIBUTE 70 THE pEATH7, f ' ~
<br />~ 38ia HAS DRGAN pR TISSUE DONATION BEEN CONSIDERED? 3D.b WAS CONSENT GRANTED?
<br />~-
<br />y
<br />J`~- YE$ ~ NO ^ UNKNOWN
<br />lad' I
<br />~ YES ~
<br />y. ~ NO VES ` ~
<br />^ ~ Nq
<br />v~. wnmc nrvu nuunn5a ur ucn i men 1 r•n i,q,lr~rv, ~, V n V rvtn S nn i yi,,.W rv VM V V llrv I T A I I UHrvt Y I 1 type a rnnq
<br />Gordon J. Hrnicek M-D. X729 N. Custe Grand Island, NE. 68803
<br />-- _.. ..
<br />32a. REGISTRAR a26. PATE FILED 8Y REGISTRAR /Ma.. Oay. Vr.)
<br />~,~~~.~,~ ~----- __. APR 1 2004
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