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1 - -�� M M <br />5 n n t.� <br />N <br />rnDy � �- � �o 0 <br />o -*� o <br />° � Co -n z CIl � <br />c7 z M <br />rn <br />Ul <br />o N <br />WHEN TNS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND INMAN SERVICES <br />SYSTE14 IT CERTIFIES TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORp ON BILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATMTICS SEC' -1"f/CH /S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE''' <br />11/1/2004 200501412 TT - <br />AsS/STAiI"FAT RE 41m- -R <br />M S <br />LINCOLN, NEBRASKA HEALTH ANDIAMIAERMM <br />EM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEgWfiAS FI_ AKr-k Si71*6RT <br />VITAL STATISTICS _ p <br />CERTIFICATE OF DEATH 4 <br />11 <br />S <br />........ MIUULE LAST <br />2. SEX _. 3. DATE OF DEATH /Month. Day. Year/ <br />Geor e Junior Callihan <br />Mal r 3 <br />4. CITY AND STATE OF BIRTH /It not H U.S.A.. name country) Sa AGE - Last Birthday UNDER 1 YEAR <br />UNDER 1 DAY S. GATE OF BIRTH /MOnM. Day. Year/ <br />Grand Island NE (Yrs.) 81 5b. MOS. I DAYS <br />' <br />Sc. HOURS' MINS. <br />O <br />7. <br />Se tember 9 1923 <br />SOCIAL SECURTIV NUMBER 8a PLACE OF DEATH <br />Curran Funeral Chapel 3005 S. Locust ST. Grand Island, NE 68801 <br />506 -20 -4712 HRF AL ❑ <br />Inpatient OTHER: Nursing Home <br />fib. FACILITY -Name /hr!ol instrtudon, give street ant number/ ❑ <br />ER Outpatient ❑ Residence <br />Grand Island Veteran's Home ❑ <br />DOA ❑ <br />Other(Spectvi <br />Be. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH <br />Grand Island, NE Yea ® Nd ❑ <br />Fall <br />_ _ <br />9a. RESr IDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION - <br />__County . <br />9d. STREET AND NUMBER /6tdudngZp Code) 9e. INSIDE CITY LIMITS <br />Nebraska Hall Grand Island <br />10. RACE <br />12300 W. Capital 68803 Yes No ❑ <br />- (e.g., White. Black. American Milian. 11. ANCESTRY leg.. Italian. Mexican, German, aft) 12. MARRIED <br />etc.) Specify) <br />WIDOWED 13. NAME Of SPOUSE /a elite. give maiden name/ <br />White (specify) <br />Irish NEVER <br />MA 1 <br />DIVORCED <br />tda. USUAL OCCUPATION /Give kind o/ work oboe during most 14b. KIND OF BUSINESS INDUSTRY <br />of working fife, even ilretrredl <br />15. EDUCATI N (,peel only highest grade completed) <br />Sales&qp4ament weldincr Suppiv <br />Elementary 1!!condary 10 -12) College 11 -4oa 5 -1 <br />16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />George E. Callin9& <br />Mollie Fani <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? FORMANT -NAME <br />26e. INJURY AT WORK <br />(Yes. no. or unk.) (If yes. give war and dates of services) WWI I Yes 8/18/1943 - 2/17/1946 dith Callihan <br />26g. LOCATION STREET OR RF.D. N0. <br />19b. INFORMANT MAILING ADDRESS tSTREET OR R.F.D. NO MTV ma Tn T.I. e ror <br />Homicide Investigation <br />633 White AV grand Island, NE 68803 <br />20. EMBALMER- SIGNATURE B LICENSE .NO. /. 109 21a.METHODOFDISPOSITION 21 b. GATE <br />e• f1 7 2 21c. CEMETERY OR CREMATORY NAME Service <br />' <br />ER -- y C " ❑ Burial ❑Removal 10 -2 /4-04 Central <br />2 <br />Nebraska Cremation <br />FU <br />22a. FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION <br />CITY OR TOWN STATE <br />Curran Funeral Chapel © Cremation ❑ Donatron 719 Front St. Gibbon <br />22b. FUNERAL <br />Nebraska 68840 <br />HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, LP) <br />Curran Funeral Chapel 3005 S. Locust ST. Grand Island, NE 68801 <br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b), AND (cll <br />Interval between onset and death <br />'(al Cardiopulmonaxy Arrest <br />DUE TO, OR AS A CONSEQUENCE OF' <br />I Interval between onset ant death <br />(b) COPD <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Interval Ittwegh onset and death <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contribuling to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY <br />PART <br />25. WAS CASE REFERRED TO MEDICAL <br />II <br />CAD PREGNANCY IN THE PAST 3 MONTHS? <br />l.C1J <br />EXAMINER OR CORONER? <br />(Ages 10 -541 Yes No Yes No <br />26a. 26b. DATE OF INJURY /MO.. Day. Yt) 26c. HOUR OF INJURY 28d. DESCRIBE HOW INeJRV OCCURRED <br />Yes No <br />Accident � Undetermined <br />� <br />M <br />Suicide Pending <br />❑❑ <br />26e. INJURY AT WORK <br />26f. PLL.gAa OF. INJURY - At home, farm, street facgy <br />office bwkling etc. /Speaty/ <br />26g. LOCATION STREET OR RF.D. N0. <br />CITY OR TOWN STATE <br />Homicide Investigation <br />Yes � <br />❑ <br />27a DATE OF DEATH (Mo.. Day. Yr.) <br />28a DATE SIGNED (W... Day. Yr.) <br />28b. TIME OF DEATH <br />O <br />N' ctober 23, 2004 <br />$ 27b. DATE SIGNED No Day. Yr) 27c. TIME OF DEATH M <br />i y 28e. PRONOUNCED DEAD /Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Moir,) <br />October 24 2004 1:00 A M n <br />M <br />3 27d. To the best of my knowledg ath occurred at the time, galg and dace and due to the 28a. On tM basis of examination and�or investigation, in my opinion death occurred at <br />causels) stated. t <br />s the time, date and place and due to the causelsi stated <br />(Si nature and Title) ► i ✓'� i ,iU`TGti✓;r'v C- �WVJ -'i� ' I' (Signature and Title) <br />29. 010 TOBACCO USE CON I Hi UTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED' <br />❑ YES ❑ NO a UNKNOWN ❑ YES ® NO ❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSI(;IAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Pnnt) <br />Dr. Sheridan Anderson, Gr4nd Island U erans Home, Grand Island, NE 68803 <br />32a. REGISTRAR <br />�32b.BY REGISTRAR /MO.. Day. Yr./ <br />OCT 2 9 2004 <br />G ll� YZ / ae y�>„ o`� ate t-P <br />