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.I~.I.. ~ ~ ~ <br /> <br />c <br />~ V7 <br />ev <br /> <br />.~-~- <br />n <br />= ~' UJ <br /> <br /> <br /> <br />a ~ ~ -•T °~ ~`' ~ <br /> <br />~ ~ ~ <br />o <br />~ ~,n ca Z <br />~ <br />U'L ~^ rn t'- ~] <br /> <br />~ ~ ~ <br />~ <br />~ <br />F"- A <br />C~J Zj <br />C <br /> ~ ~ CV ~ ~ <br />~ U. '°"` <br />' <br />' C~"1 <br />.Ittlllllllllllllll~~ ,..~ - <br />- <br />~^ -~ ~ ~ <br /> <br />~li~l <br />Gra V <br />- _ _-.The West Half (W1/2) of the North Twenty-eight (2$) feet of Lot Three (3) and the <br />West Half (W1/2) of Lot One (1) in Block Twenty (20) in Scarff's Addition to West ~ <br />Lawn in tk~e City of Grand Island, Hall County, Nebraska. <br />~~ <br />WHEN THIS COPY CARR~S TFE: RAISED SEAL OF THE NEBRASKAILTK, ~RI(1CES <br />SYSTE'A~, R CERTIFIES THE BELOW TO BE A TRUE COPY OF ~ ~~~.'k~!VYITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, At. Sam/ - '~fELflC~,`'I~4I1CH l8 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. = ;;;;; - <br />-~- ,- <br />DATE OF/SSUANCE 2 0 0 9 0 9 0 5 4 s , <br />JAN 1 8 2002 ~ ~ ,= S~~~R <br />LINCOLN, NEBRASKA HEALTI4 ~~', <br />STATE OF NEBRASKA- DEPARTA~TI OF fR:AI,TH AND ~~~~ S(Jppp <br />VITAL STATISTICS (~~} _ <br />CERTiFICATE OF DEATH~~ ~~ <br />t. DECEDENT -NAME FIRST MIDDLE LAST 2 SEX y 3. DpYE OF~DEATH (MOnlh. pay. Vearl <br />John C. Chaulk Male Se tember 29 2001 <br /> <br />4. CITY ANp STATE OF BIRTH 111 not in US.A.. name cdunlry) Sa. AGE • Last Birthday UNDER 1 YEAR _ <br />UNDER I pAV 6. DATE OF BIRTH /MonM. Day Year) <br />(Vrs.l Sb, MOS. DAYS <br />Tecumseh, Nebraska $p ' 5C. HOURS' MINS. <br />Au ust 24 1921 <br />7. SO <br />CIAL $ECURTIV NUMB <br />E~ Ba. PLACE OF pEATH <br />C <br />p <br />~ 506-03-5088 HOSPITAL: ® Inpatient OTHER; ^ Nursing Home <br />66. FgCILITV-Name /!loot inslilulbn. glue Street and number) ^ ER Outpatient ~ Re6idenca ' <br />St. Francis Medical Center ^ nDA ^ Dtner/Specdyr _~ <br />Bc. CITY. TOWN OR LOCATION OF DEATH Sd. INSIDE CITY LIMITS 8e. COVNTY OF DEATH <br />Grand Island Ye6 ®Np ^ Hall <br />9d. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Cad $ 803 9e. INSIDE GITV LIMITS <br />Nebraska Hall Grand Tsland 2411 W. 18th Street Ye6 ® Np ^ <br />I o. RACE -leg.. White. Black. Ameilcan Indian. I t. ANGESTRY (e~g.. Italian. Mexman. Garman, etc! 12. ®MARRIEO ^ WIDOWED 13 NAME OF SPOUSE Ill wAe. give maiden name/ <br />S <br />etc.! I <br />neoryl ISpecifyl NEVER <br />White American DIVORCED Gracie Harpold <br />14a. uSl1AL OCCUPATION !Gros kind o/ work done during mdg/ 146. KINp DF BUSINESS INDUSTRY 15. EDUCATION ISpeclty poly highest grade completed! <br />p/wprkrn <br />4/e <br />even it } <br />lir <br />d/ <br />g <br />, <br />e <br />e <br />Elememary or Secondary 1o-12) College It -4 or 5•I <br />Engineer _ Tele hone 12 <br />16 FgiHER -NAME FIRST MIDpLE LAS1 r7. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />_ Cy NMN Chaulk Unknown <br />15. WAS OECEASEp EVER IN U.S. ARMED FORCES? _ <br />t9d. INFORMANT-NAME <br />(VP.S no yr unk.l Ilt yes. ewe war and dates rn services! <br />Yes unknown M k J. Cha k <br />196 INFORMANT MAILING ADDRESS 15TREET OR R.F.D. Np., CITY OR TOWN. STATE. ZIPI <br />4624 Grassrid e Road Lincoln, Nebraska 68512 <br /> <br />20. EMBALMER -SIGNATURE & LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />216. OATS _ <br />21c CEMETERY OR CREMATORY NAME <br />Not Embalmed _ ^Bunal ^Hemoval Se t. 29, 2001 Westlawn Cremator <br />2?a FUNERAL HOME ~ NAME ~ 21 tl. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin stop-Sondermann F.H. ®Cremalipn ^ppnalwn Grand Island, Nebraska <br />226. FUNERAL HOME ADDRESS 15TREET OR R.F.D. NO.. CITY OR TOV/N, STATE, ZIP) <br />601 N. Webb Road Grand Island, Nebraska 68803 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. 161. ANO Icll I Interval between onset and death <br />PART t I <br />lal I r.... <br />OUE 7D. OR AS A CONSEOV NCE OF. I Interval between onset and exam <br /> <br />..~~ I <br />t Ibl I <br />I <br />__ <br />DUE TO, OR p5 A CON EOUENCE OF: I Interval between onset and death <br />I <br />Icl l <br />OTHywfl6dIFICLIIT C~N[llTION6 rCantlAionq~pntribypVg b the da0m but rwt related PART III IF FEMALE. WAS THERE A 24. AUTOPSY l 25. WAS CASE REFERRED TD MEDICAL <br />PART \ ~,.1 V tl L~ L Llil C: l 1 V Il 1. C i7 L / <br />PREGNANCY IN THE PAST 3 MONTHS? x EXAMINER OR CORONER? <br />1 '~ <br />~ <br />" v <br />, <br />(Ages 10-541 Y09 No YBS Na Ves N <br />26a. 28b. pgTE F INJ Y /Mo,. y. Vc/ 25c. H OF INJURY 26d. DESCRIBE NOW INJURY OCCURRED <br />Accident ~ Undetermined <br />M <br />Sui cide ~ Pending 26e. INJURY AT WORK 261, PACE QF~JURV %At h~, !arm, 6tr <br />o ice burMli etc. SP9o gel. Ledory 26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE <br />Ho ^ ^ <br />micide Investigauon vas No <br /> 27a. DATE OF DEATH lMo.. Day. Vr,J 28a. pgTE SIGNED /Mo., tlay Yr/ 28b. TIME OF DEATH <br /> <br /> <br />~ <br />~ o 276. DATE SIGNED /Mo.. Oay. VrJ <br />a <br />~ 27c~ TIME OF pEATH <br />_..-... <br />_ ~ ~ g <br />~ a ~ 2&. PRONOUNCED pEAp /Mo. Day, Ycl 26d. PRONOUNCED DEAD /Hour/ <br />_ ..-..--.._.. <br /> <br />~_ u1 <br />- ... <br />g M + <br />g F M <br /> 27d, Tp the befit W my knowledge. Beam occurr at the time, and ace dlld due m me <br />causelsl Stated z <br />; ~ ~ <br />a <br />Q 28e. On the basis of eKammaapn dndror investigation, m my opinion death occurred a[ <br /> . ~ the dine, dale and pldCB drd due to the ceuselal 9tdkd. <br /> S' nature dnC Tide Si nature and Ti11e <br />29. DIO T OBACCO USE CONTRIBUTE TO THE DEA ? 30.a H GROAN OR TISSUE p ONATION B <br />E EN <br />C <br />ONSIpERED? 30D WAS CONSENT GRANTEp? <br /> <br />VES ^ NO UNKNOWN ~ YE ~ <br />S I 1 <br />~ <br />f / <br />' <br />~y <br />Y NO ./ ^ VES IVI NO <br />L 17` J"~' <br />31. NAME AND ADDRESS OF CERTIFIER IPHVSICIA ,CORONER'S PHYSICIAN OR COVNTV gTTORNEVI /Type a Pri <br />nl/ <br />Kimberl A. Mickel M:D.'729 N Custer Grand Island, Nebraska 68$03 <br />32a. REGISTRAR 32b. PATE FILED BV REGISTRAR /Mo,. pay. VcJ <br />_ ~ tit. OCT 2. ~nni <br /> <br />