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<br />Lot One Hundred Six (106) except the Southerly Three (3) Feet thereof, in West Lawn
<br />Addition, City of Grand Island, Hall County, Nebraska
<br />WFIEN TH/S COPY CARR/ES TF� RA/SED SE'AL OF THE NEBRASKA HEAI.l"�l Al�(D�t�Es
<br />SYSTEM, IT GERTIF/ES THE BELOW TO BE A TRUE COPY DF TNE' ORIQ/NAL �� �� t
<br />TNE NEBRASKA HEALTH AND NUMAN SERNICES SYSTEM, VI1"AL STA7"1��� �'�k � k
<br />THE LEGAL DEPOSITORY FOR VITAI. RECORDS. r . F �'� := _ "":': "
<br />�
<br />DATE OF /SSUANCE � �� � , . �F�
<br />FE� � 1999 2 O 10 U 8 2 7 3 � �:�
<br />LINCOLN, NEBRASKA MEALrFI AND HU�G4N�TE�
<br />srarE oF r�EaR,as�c,�- nEr�R�'�rrr oF [�ar.Tx nrm xvMaiv s� Fuvi�ia�E �3n s�poxT
<br />vrrn[, srwr[sncs =' ' - _
<br />CERTIFICATE OF DEATH �"���
<br />t. DECEDENT • NAME FIRSi MIODLE LAST 2..5EX 3. DATE qF DEATH lMonlh pay. Yeaq
<br />Harold Orville Clark Male January 23, 1999
<br />4. GTV AN� S7A7E OF BIRTH lMnof rn U 5.A.. nems coun(ryl 5e. AGE - Lest BlMday UNDER 1 VEAR UNDER t pAV 8. DATE OF 81RTH /MMeh. Oay. Yead
<br />�Vr6.1 , 56. MOS� I pAYS SC. HOVRS' MINS. � O�� 19l+
<br />Clay Center, Nebraska
<br />� 7. SOCIAL SECURTIY NUM9ER BB. PLACE OF DEATH
<br />� 506-20-3803 FIOSPI7AL: ��npetleM OTHER � Nur6mg Home
<br />� Bb. FACILITV • Name ln�rohnelNu�an, piWBheN�MnunrOK) ��R �Oa�ent � Rea�danCe
<br />� Howard County Community Hospital ❑�A ❑ a��rs��rv
<br />BC. CITV. TOWN OR LOCATION OF DEATH Bd. INSIOE CITV �IMITS B0. COUNTV OF DEATH
<br />St. Paul v.. �] No ❑ Ho'ward
<br />9A. , RESIOENCE - STATE 9b. C9UNTY 9c. CITV. TOWN Ofi LOCATION � 9d. STREEf AND Nl1M8ER IlrrcludinyZip CPde! 9e. INSIDE CITV LIMITS
<br />� ..._ _ -... __.. _ . . . - _ -___ . .-�.:-:_�... �_.�.,_.- -.
<br />Nebraska Hall Grand Island 1719 North Husfnn, b�8U3` �,; �] No ❑
<br />10. RACE • IY.q„ Whflp. Black� Amprqpn Indien. 11. ANCESTRY I�.q.. �4n, AA�KiCUI. U�rrNh. NCI 1 �2,� MAARIED ❑ WIDOWED 13. NAME OF SPOUSE /tl wile. give mpMen neme�
<br />�Bt�ll�plCiNl �g�fi'�• 1Q NEVER DIVORCED Darlene Weaver
<br />wn ze American
<br />14a� USUAL OCCUPATION /G�ve krnd d wrrk dens duNnp moa� ,�r,� 110. KIND OF BU31NE5S INDUSTRY �/ 1 O 15. EDUCATION �SpBCily only higlWe� Qrpd! cwnplelitl)
<br />�7 wwor4mg 6re. even rc:srirodl (JC� ''� � Elam�yery w$�candary 10-12) Cdlege 11.4 or 5�i
<br />, Co-Owner Sanitation Company <<
<br />; 18.FATHER•NAME FIRST MIDPLE LAST 17. MOTHER FIRST MI�DLE MA16EN 5URNAME
<br />� Orville Clark Velma Herrick
<br />� �
<br />� 18. WAS DECEASED EVER IN U 5. ARMED FORCE57 ���ZgI�945�� 19a. INFORMANT • NAME
<br />(Veg. no. or unk.) ' III yes g�.�a wir uq cates al wnk��;
<br />Yes World War II l iil7/1946 Darlene Clark
<br />196. INFORMANT MAILING ADDRESS ISTREET pR R.f.O, NO.. CITY OR 70WN, STATE. ZIPI
<br />1719 North Huston Avenue, Grand Island, Nebraska 65803 �
<br />20. OALMER - SI�NAT 8 uC ENS . _ 21i. METHOOOF DISPOSITIpN 21D, AATE 21c CEMETERV DR CREMATORY NAME
<br />/
<br />�].BW,,, ❑ pa,„,�,� O1/27/1999 Grand Island City Cemetery ^
<br />0. AL M- NA 21d. CEMETERY OR CREMA7DRV LOCA710N CIYv 0.1 TOWA: STATE
<br />Apfel-Butler-Ged.les Funeral Home ❑ c�+�+ ❑�_�^ Grand Island, Nebraska �
<br />22b. FUNERAL HOME A�DRESS fSTREET OR R.F.O. N0. GTV OR TOWN. STATE. ZIPI
<br />1123 West Second G� Island, Nebraska, b8801-5899
<br />23. IMMED�ATE CAU5E ENT ONIY ONE CAUSE PEq LINE FOR 1a61h1. AN� �CII Interval ne(weea an5e1 antl tleam
<br />PART I
<br />-� I Ia1 �� � �� �
<br />Ol1E 1'0. OR AS A CONSEOUENCE OF. � Inlervai batwean onee� and dealh
<br />�
<br />� (b � I
<br />�� � �uE TO OR RS A CO:�SEOUENCE �F� ; intervel beiwgon On6et and deam
<br />(e'
<br />PART �TWER SIGNIFICANT CONpT1pN5 •'f:p10Ni0M COnCIWNrq tD 1M Oestl� MA naA rolAlsd PpEGNANCY N HE PAST 3 MONTHS� Z4 AUTOPSY ZS EX OR CORONER MEDICAL
<br />II Vps No
<br />. �qgss 10-54) Ysa Na Ye6 Na
<br />26d 26b. I]ATE OF INJl1RV I�t�o.. Par. vr.l 26C. HpUR OF INJURV 280. DESCRIBE HOW INJURV OCCURREO
<br />� ACatlent � UndtllO�m��etl M
<br />� Suicitla � Pentling I 26e. INJUpV AT WORK 281. P C F • , larm. atrael,laCtpry 26g. IOCATION STfiEET OR R.F p. N0. C�TY OP TOWN � _ STATE
<br />❑ ❑ w�ce �u°�np. etc. I ''�" �P
<br />� Homicida InvesUgauon Ves No
<br />27a. OATE OF DEATH (Ma. Oay. Yc/ � 2Ba. DATE SIGNE� /Ma.. Day. Vil 286 TIME OF DEATH
<br />��4
<br />5c�� �.�� 3 1`� `� � ��� M
<br />� �' 27b DATE SIGNEp (MO.. Day. Yr. 27c 71ME OF DEATH � i 2Bc. PRONOVNCEp �EAD /MO. �dy. Vcl 2Bd. PRONOUNCED OEAD /Fbud
<br />'��� �_'.�� ���( "� �- a�n 'P M �a��
<br />J g � � M
<br />27d. 7o me 6est d my knowleege. eesth xcurred a! th9 Nme, tlata a Olace and due te me °�� 28e. On 1ne nasis ol aKammauon a�M�ar investigauon, in my oqnion dealh cecwred at
<br />J o causelsl sta�ed. � r. � t�+e ume. da�e arw p�ace and due to �ha ceusals) stated.
<br />j �Si nalura anG Tele �' �� �� 5� naWre aM Tdle
<br />29. �ID T08ACC0 USE CON7fiIBUTE TO E DEA7H9 30.a HAS ORGAN OR TISSUE OONATION BEEN CON5IDERED? 90.6 WAS CONSENT GRANTE�?
<br />� VE$ � NO � UNKNOWN � YES � NO � �ES � NO
<br />31. NAME AND AD�RESS OF CEi7TIFIER IPHYSICIAN, CORONER�S PHVSICL4N OR COUNTV ATTORNEYI (7ype or Prinll
<br />Jean-Louis Pare, M.U., 1004 Indian S reet, St. Paul ebraska 6� �"l 3
<br />32a. REGISTRAR 3Zb PATE FILED 8V REG15TR9R �1g. Oay. Yc%� ��
<br />s., � - FE '� u
<br />r. U �� �
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