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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUM~~kt~iaCESr_XT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP„A~M , Ofi;EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE' LEGAL DEPOSITORYFOR VITALREGQR"D~1 ~~ :;~ , '~' r ~'
<br />DATE OF ISSUANCE I~ ~`~~ "
<br />STANLEY'S: CO~PE~R -- , .
<br />MAR 31201D o~Pa~~~- ~ .~~~ R ,, ;,-
<br />201002284
<br />LINCOLN, NEBRASKA HUMAN ,~EIRVICf$ = tw .+
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<br />4;,.3 ,.
<br />STATH OF NEBRASKA - DEPARTMENT OF HEALTH AHD HUMAN SERVICES ' r ~ w ~ ~ • .y "' ~ ~ ~~"r IXy...,.
<br />CERTIFICATE OF DEATH _
<br />4. DECEDENT'S~IAME (First, Mlddla, LaaL SuMia) 7, SEX $,DATE ATH.(Mo.Ipay,Yr,
<br />Harold Glenn Day Male December4, 2007
<br />4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. ACCLast Birthday S0. UNDER 1 YEAR Se. UNDER 1 DAY 5. DATE OF DIRTH (Ma., Day, Yr.j
<br />(YK I NOS, DAYS HOURS MINE.
<br />Clearwater, Nebraska 83 May 22, 1924
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<br />+ 7. SOCIAL SECURITY NUMBER a4 -LACE OF DEATH
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<br />rL ]23-~a-6366 HOSPITAL: ~ InpatNnf YH R: ^ Nur6lnp H°mpfLTC ^ Hnapiq Facility
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<br />a6. FACILITT.NAM! (11 not InHNuliPn, qlw aural and nYm6ar)
<br />©T?RlOulparlanl ~ DaCadanl'a Ham.
<br />a Saint Francis Medical Center ^ pqA ^ Dtn.r(spaeiry)
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<br />sJ -e, CITY DR TOwN OF DEATH (Inctyda Llp Coda) ~ -d, COUNTY OF DEATH
<br />w Grand Island 68803 Hall
<br />Z 9a. RESIDENCE.STATE -b, COUNTY pe. CITY OR TOWN
<br />LL
<br />Nebraska Hall
<br />Grand Island
<br />,a
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<br />ed. STREET AND HUMDER
<br />-a. APT, ND. 9f. 21P CODE
<br />-q. INSIDE CITY LIMITS
<br />w 2519 W. Forrest 68803 6] r.a ^ N°
<br />d t0a. MARITAL STA775 AT TIME OF LEATH ®Manpd ^ Nrwr Marr 6d 104. NAME OF SPOUSE (FIn4 Middle, Laat, SuKaj 11 wile, qiw maiden name.
<br /> ^ Married, put pparae°d ^ Wldowad [] Divorced ^ Unhn°wn
<br />
<br />d Anna Evalene VanSlyke
<br />E 71. FATNER'q-0IAME (Pleat, Middle, Vat, Suln.j 1;, MOTHER'SaIAME (FIn4 Middlp, Msldan 5umampJ
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<br />Charles Da
<br />Genie Ra land
<br />m t7. EVER IN U.E. ARMED FORCEST Giw daNa of urvln If Ys. T4i INFORMANTJ7AME 1.4. RELATIONSHIP TO DECEDENT
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<br />(Ya., Nd. ar unk l ND
<br />Anna Evalene Da
<br />Wlfe
<br /> 1S. METHOD OF DISPOSITION
<br />~-"K" ^"°"""" 16a. EM MER-SIGNATURE
<br />~ 186_ LICENSE ND.
<br />'mi 7-c, DATE (MD., Day, Yr.)
<br /> ~ l X43
<br />
<br />~[ram"pn ~Emwnbnvtne ~
<br />.. December 5, zoo]
<br /> ^ItamarN ~Dnw.lspadryl t-d. CEMETERY, CREMATORY OR OTHER LOCATION CITYrTOWN STATE
<br /> Ord Cemetery Ord Nebraska
<br /> 17a. FUNERAL HOME NAME ANO MAILING ADDRESS (StneL Clty ar Town, Blatp) 17h. Zlp Coda
<br /> Livingston-Sondermann Funeral Home, 801 N. Webb Road, Grand Island, Nebraska 68803
<br />TT CAUS!~~E~ OF DEAT, H (see instructions and examplE
<br />~ yt i 1. G"Hr rna [/1L._, aranLL . aiuaaM. wy.rw., p W,npVea4eM-YM tli,KlW.aur.Y IM apm. DO MOf .nl.r prmlWl.+MNarc~ a. uNlri a!r/a4
<br />~apiraenry aural. w .ame~eWar IIbrI1lNlen •IIM°„l an°winp 1M Nbbpv- DO MOT AaiREVIATS. Enlar only ana caw/ On a ans. Atltl atltlYlanal YMa Mlwaaraary.
<br />IMMEDIAT ~AU$E:
<br />IMMEDIATE CAUSE IFfnal
<br />diaaau °r condition r•tlullinq //~y~ /j ~F ~ '
<br />In dpth) ~ / (J 4v`~L~
<br />oval Id death ~ ~)
<br />l~ ~~f1.c~L
<br /> DUE TD, OR Af A C/ONSIOUEHCE pF; n]
<br />$agn.nlially liar ednditlona, If ~,>t .~~~, ~ ~ /f~ /1 _ ~~ / /~ ^ ~~~~ "
<br />any, Ipadlnp t° the caY4p laand -~(i i f+ ~~j' rl.!c J ~~L~ .~~" ' pgss 1° dpalh
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<br />~ on Lnp a. DU! TO, OR AS A CONSBpVENCE OF: ~
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<br />: onW7~rl daac~ h ~~'
<br />I Endr the UNDERLYING CAUSE c)
<br /> (diapaaa or In(ury IhpA ini4and
<br /> [ha awlda nsldnp In death) qUE T0, OR AS A CON$EOUENCC OF: : onaat 1° death
<br /> LAST
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<br /> /IE-PAR OTHER`IONIFICANT CONDITIONSxandltlana c°ntr;butinp le the dnth but not n.u4inp In IM und°rlyiinp eauaa glron In.pART I. 1-, WAS MEDICAL EXAMINER
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<br />• f~/,~ OR
<br />CORONER C XTACTED7
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<br />YES
<br />NO
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<br />ttl 10. IF FEMALE: \7rfia.-MANNER OF DEATH $16. IF TRANSPORTATA)N INJURY 71C. WAS AN AUTOPSYpERFORMEDT
<br />~ ^Nol prvpnant within psi year durN ^ Homicide ^ grfrpdOparalw ^ YES NO
<br />W ^Prapnanl a1 Nma °! doom Aepdanl ^ pending InwNigation ^ Pspangae
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<br />^NOl prapnant, but propnanl wltnin 47 day. d derth
<br />~ 8uiclda ^ CDU1d not b• datarmtnad
<br />^ Padapirlan 77 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CA 8E OF DEATHT
<br />d ^NOl pnptnnL but prppnpnt 17 day. (D 1 year 6afon death [] Other (5paclly) ^ Y!S ~O
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<br />ra ~,]Unanown If pregnant within the peal you
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<br />O IIa. DATE OF INJURY (Mo., pay, Yr,) 716. TIME OF INJURY 77C. PLACE OF INJURY-At home, farm, atrpaL Hctdry, ofriN 6ulldlnq, c°natnlctlon dN, ate. ($padtyl
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<br />17d. INJURY AT WORK? IIa. DESCRIBE HOW INJURY OCCURRED
<br />7iL LOCATION OF INJURY.6TREET R NUMBER, APT. NO. CITYROW N BTATC 7JP 600E
<br /> DAY! OF DEATH (Mo., Day, Yr,l =
<br />r Iaa. DATE SIGNED (M°., Oay, Yr.j 146. riME OF DEATH
<br />a~ eC:E'mber 4r 2007 $'uz
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<br />r 4~ DATE SIGNED (MD., Day, Yr.) 2JA71ME OF DEATH $ ~ 4 340. PAONpUNCED DEAD (Ma., pay, Yr.j 24d TIME PRONpUNCED DEAD
<br />~'~,~ a em er 10, 2007 9;50 m yr`z
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<br />v 2] a Ih at my kne~tadpa,paath occurred at the Uem, dau and place W g 7M. On Ina 4atN of aaaminatlon andlor InvatllgaUnel, In my Dp41i6n death occurred
<br />r ` a Y ' o a e~ IAj sea . (-lgnatura~)
<br />/ p ~ u ar 16r tim., dau and place and dw 1° Iha wus(p).lat.d. (Sipnatura and Tid4)
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<br />.F'~~ ~
<br />+~ ~~DID/~FO/§ICCD U$E CONY eUTE TO THE DEATHT
<br />~ ^ lE8 ^ NO PRpeAEtLY ^ UXKNDWN
<br />AME'TdLE AND AODAESS OF CERTIFIlR IPHYiIGI
<br />Dr John A Wa once MD
<br />1-a. REGISTRAR'S SIGNATURE
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<br />7rYa. NAS ORgAN OR TI55UC 0 NATION BEEN CONSIDERED? ~- WAS CONSENT GRANTEDT
<br />[] YES ~O Nd Apptlca6la 1116a la NO ^ TES ~q
<br />CORONEA'$ PHYSICIAN OR COUNTY ATTORNEY) (Typo or Pnnt)
<br />900. Aloha w t^ronrl Tel -. r.a \T Lr Gnnn~
<br />. Ir ~ 11-b. DATE FILED CY REGISTRAR IMo., Day, YL)
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