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�- . .. STA'TE O� NEBRASKA
<br />WHEN TNIS COPY CARRIES THE R.4ISED $EAL OF THF NEBRASKA DEPARTMENT O�' t�YL� �I lv�G��'ES, IT CERTIFI�S
<br />TH� B�ELOW T� BE A 7'RUE COPY OF THE ORIGINAL RECORb ON FILE WITH 7NE NEBRB$ �� H�ILTI! AND
<br />HUMAN SERVICES, VITAL R�CORD5 OFFICE, WHICH IS THE LEGAL D�POSITCqR1""FD,¢'V�� ��'�� `
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<br />PA7'E pf ISSUAIVCE H ��j���
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<br />LINCOLN, NEBRASKA ����.� r , .. � ,.�
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<br />STATE OF NEBRASKA - DEPARTM�NT OF H�ALTH ANP MUMAN SEF�V��'�,T �; ��� '����
<br />CERTIFICOTE �F �EO7H 1 � J °� _ _ -
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<br />John James Hetfield
<br />4. C1TY ANO BTATE 012 TERR11'�RY. OR FOR�ICaN CAUWTRY OF 81HT►1
<br />Loup County, Nebraska
<br />I. SOqAL SECURfTY NUYB�R
<br />'!a FAl�LL1T1//diAME (R nM Matltupan, giva alra�! NM rNmMt)
<br />Good Samaritan Health Systema
<br />&. C(TY DR TOWN QF DEATH (Include Lp Cada)
<br />Keamey 68848
<br />i�. RE8IPENC�STATE B6. COUNtV
<br />Nebraska Mall
<br />9d. STREET AN� NUMBER
<br />2632 Narth Bluff Center Road
<br />7aw. MARITAL STATUS wT TIME UF 4EATH � MuAsd ❑ Nwer fAu
<br />❑ M+urtad. 6ut saP� 0 Widawad ❑ Oiviorcad � UNawwn
<br />17. FAIHER'8-NAME (Flral, M�ddle, Lra4 Suftix)
<br />n.aex -R1�wr� ^s4!�o.a[�IF�)
<br />Male MarGh 29, �d'7 ? �"� �`
<br />W, pSiE-Lpt 61Mday 6p, UNDER 1 YEAR 6c. UNqER 1 DAY 8. DA7E OF BIR7H (MO.; pn1;� �*,;, _^�
<br />(Yrf.l M09. DAYS NOURS NINS. � .. � _
<br />70 Odober 12, 1939 �
<br />8a. P4ACE OF pEATH
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<br />Bd. COUNiY pF DEA7H
<br />Buffalo
<br />Yc. CITY OR TOWN
<br />Cairp
<br />I 9s. APT. NO. I et. LP C04E 24 I 9W I�N �� N MITS
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<br />70b. HAME OF SPDUSE (KI� Mid�. Lpt, Sufqx) IF wNs, �w m�dan nam�.
<br />Beverly Aflarkvicka
<br />il M07HER'&NAME (FIra4 Mideqa. M70den Swnen7l►
<br />�rances Starke
<br />ta. EVER W U.& ARYED FORCES7 Giw d�us W aeMar NYra � 1�a. �NFORMAN7-NAME
<br />76. MHTNOU OF WSPOSIiION 18a. ¢M�k NA� 161i. LIC� SH NO.
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<br />��� ��� 19d. CEMETERY, CHEAAATORY OR OTHER L N G7YITOWN
<br />Taylor Cemetery T'aylor
<br />17r. FUNERAL HOME NAME ANp NWLIHG APONESB (Bkwt, Ciry a Town, SpEs)
<br />Jacobsen-Greenway Funeral Home, 411 O Street, PO 6ox 112, St. Paul, Nebraska
<br />MsP��ory uti.l. of w1lMculaf R6MI�tlon wiMaut �ha`W�q tlu �tlolopy. pO NOT A9BR8YIpTl. E11M wdy oM uup on e Xn.. !Wa Wtlitle�rt rtnN iI1Me�.+ary.
<br />NMMEP6A7E CAU$E:
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<br />on lin� a p�E t0, OR AS A CONSEOUENCE OF:
<br />Enl�rths UNDERLYIN(i CAUSE F)
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<br />tl�a avaMa �sultlny in dMth) WE 7q, pR A$ A CONBEpUENCfl OF:
<br />LAST
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<br />18. PpRT u. OTHER SWNIFICHNT CDN01TlONS�l;ondNiens conpibutlrp tp pH dwth 6ut nat rl�uitlnp In tlYS undarlyinp caue� qiran In PAR71.
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<br />W �• �F F��-�� Y1a MANNER OF PEATM 774. IF TppNBPQRTATION INJUF
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<br />❑Not perp�wM, but pnp+we vr�Wn 4R d�yr of �slh ❑ 9u1Wd� ❑ Could not bs d.tuminad �] PMktrlen
<br />� ❑� Pry9^+nR 6ut pApnwt �/3 dnYa m t v� brfar+ dieth [] �� 1�9)
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<br />11b. REIJ11'IpNSMIP TO qECE�ENT
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<br />18c. WIT� (Mo., Uay. Yr.) -
<br />April 2, 2010
<br />� STATE
<br />Mebraska
<br />�ro. z�P cad.
<br />68873
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<br />;onsetta death
<br />10. WAS YEp�CAL EXpMINER
<br />OR CORON�R CUNTACiEP7
<br />�Y� �ND
<br />21c. WA8 AN AU7OP8Y PERFORMEDT
<br />�] YE$ �O
<br />,�1d. VYERE AUTpPBY FlNDINGS AVAILABLE
<br />TO COMPLE7E CA�ISE OF DEpTH7
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<br />���, '�' DATE OF INJIIRY (Mo., Oay. Vr.� 2�b. 71ME DF INJURY 22c. PLAGE Of INJURY-At nam�. farm, ehr�t, f�ctory. cfllcr bWldlnp. cwnlnxxion atte, etc. lgp�yy)
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<br />� 22d INJURY A7 WORKT 27l.�DESCRIBE IKIW INJURY CCCURREO "" � -.. .. . ..
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<br />Y$/. LpCAT10N OP uidURY - 8TREEt b NUMBep, APT. NU. CRY/TCNNN STATE YIP COUE
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<br />27a. �ATE OF pEA7H (Mo„ O�y, r.) ,Yda. DA7fl SIGNEO (Mo., Dpy, Yc) ?,4e, nME OF DEArH
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<br />� Iib. [IAtE ED (Ma, tlry, Yr.) 29c. TIME OF DEATH g>� Zqc, pRONOUNCEC DEAD (Ma., pay, Yr.) 2qd. TIME PRdNOUNCED UEAO
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<br />t,�3 Q Tad. To the bnk ot my Iu�owNdy�. dsatl� occwnd u the 11ms. drta and plucs �� Z� Tia. On tM bair of axa�WnWon arMlw Ipva�flyaqcn. in my oplNon de�th occumd
<br />�� rnd du� m� a) 1 +�d 71�s) � �� � tl tlw tlme. c{W �nd ptacr u�d dua to tM cauae(s) st#t�d (Sipnaturo arW Tida)
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<br />25. Dlp TdepCCO USE CpN1RI8U7 E DEA H? Y!a HAS DROAN OR T188UE 40NATION 6EEN CONBIQER6D9 R86. WA8 CONaENT 6RANTED7 �
<br />❑ NO [] WROBABLY [] UNKNCWN ❑ YES O Not Appuwbla M 2Ba 1� NO ❑ YE8 �NO
<br />4'1. N E, T17LE D ADdtEBS R7IFIHR (PHYffiICIAN, PHY$4CIIW ASSISTANT, COR NER'S PHYSICUAN OR CqU TY ATTORNEV) (Typ� w Print)
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<br />Yer. REGISTRARS $IGNANRE ♦.,, ,:,.. / Rlb. AATE FlLEU BY RESiI$ZRAR (1lb.;il�aYt)
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