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' WHEN 7kfS COPY CARRlE3 THE RAt3ED 3EAt OF THE NEBRASKA HEAt�i�J AND Ht(MAN
<br />SIISTEIY� ? CERt�S THE BELOW TO BE A TRUE COPY OF.THE ORll3lNAL R��'Q���`' �„ '�
<br />THE NEBRASKA HEALTH dN0 HUMAN SERHICES SYSTEM, VJTAL STATIST/�;iFt:�'f� ����
<br />THE LEGAL DEPOStTORY FOR WTAL RECOROS. _ ; _��y, _:
<br />bATE OF /SStJANCE 2 O�, 1 O 1 V V� "`=`� �- V��
<br />������ � PE#t _-
<br />_ _.
<br />__ assrs�,a�s,���� � __ ,
<br />_ LINCOLN, NEBRA SIG4 HEALTH � HUl4l�4fit �'�l�€ItfC[$�1EYS��JYt _
<br />STAtE OF NEBRASKA- DEPARTMENf OF F�ALTH AND HUMAN SEA1E'iCESr�PH�I�
<br />YTfAL STATIS7ICS �- 3 U O V� Q
<br />CERTIFICATE OF DEATH = -
<br />L DECEDENT - NAME � PIRST .� � MIDDIE IAST � 2.'SE% , 3.. OATE OF DEATH /Mo�m. Day Year)
<br />Karl Ta lor Macl�innon Male` Januar 28, 2003
<br />a. CITY AND$TATE Of BNiTH tlfnotin USA. namB toonby) . � Sa. AGE - Last &rthday UNOfR t VEAA UNOER t pAY � 6. DATE pF gIRTH /MOnfh. Day. Yearj �
<br />"oncordia Kansas tY�s.� 87 Sb. MOS ' DAYS Sc HOUR5' MINS ^^ ��'
<br />tJt� AJC 1915
<br />7. SOCtAt SECUATIY NUMBER � � � Ba. PLACE OF DEATN . . � �
<br />� . HOSPITAL: � Inpatierx OTHER: � Nws�nqHOme � �
<br />8b. FAC4ITY - Pleme (X nof inSkYu(ron, qiva street artd numberj � . A � � ER Outpatiern � Res�tlence � �
<br />� DOA � . Olher (Spec�lYr . .
<br />Wedaewood Care Center
<br />� 1NSIDE C1TY LIMITS 8e. COUN7Y OF OEA7H . . . �
<br />Yas � ^� ❑ Hali �
<br />OR IOCA� ION .� . 9d. STREET nND NUMBER 11nc1udingZipCodeJ 9e. INSiDEC1T
<br />W J ssso Yes
<br />WIpOWEp 13. NAM@�OPSPOUSE (IJwde.givemaidenname)
<br />DiVORCED getty Lou Keller
<br />.� 15. EDUCATION [Speciy oNy Aighestgrade campleted�
<br />ElementaryorSeconaary�0-�2� .' Cofleget�-aor5�1
<br />to. RacE • �e.g., wnne. B�act. amencan k�aan. yt, ANCES7RY �e.g.. Nalien Mexican, German, etc� i2. � MARPoI
<br />e1F.i (SpeciN) (SPe�ih11 NEVEP
<br />W�'11�2 SCOtt7.5Z'1 R �
<br />74a. USUAIOCCUPATION /Givekinddwmkabrndwrbgmast 14b. KINOOFBUSMESSINOUSTRY �
<br />� of wnrku�g Ii1e aven Araliredl � . ..
<br />Accountant p„ry;� Ilnnn�in�-inn �
<br />Y lIMlTS
<br />No �
<br />�o. r.v�r�tn-rvAree ruCit M�u�tt LAST . : 17. MOTHEF� fIRST MIDDIE MAIDENSVRNAME
<br />:Ross Ta lor Charlotte Sargatz
<br />18. WAS DEC£ASE� EVEFi IN U.S. ARMEO FC/qCE$? � � 19a lNFORMANT • NAME � .
<br />��. (Yes. no: rn unk.l � . � pl yes: give war� aM Cates M service5) . � � . � � � � � �
<br />� . , _ .. . . . : . � � �. �� . � . �. �� . . . . . � .
<br />��.'4_ _ , B2t� �;t1i10I1-
<br />� 9b. WFORMANT �.�. MAfLiNG ADOR SS �� �tSTREET OR R.G,D. Np., CiN OR TOWN, STATE ZIP� . ,., :
<br />.�104 W 17th Grand Island Ne}�raska 58803� '
<br />---- -
<br />�ZO EMBAIMER-SIGNATUAE6l.ICENSENO. 21a.METHOOOFDISPOSITION � 2f0. DATE Januar Z�c. GEMETERYOR
<br />�Q y �,,,7,,,.�,,,,,, Y
<br />li e1lWQlltl�.i . � :.: . ��Remov8l .. � �
<br />—___--_ _.._ �:—___-. .
<br />22a. FUNERnL HOME - NAME � , � 2id. CEMETEAY OR CREMATORY IOCATION
<br />Kleine Funeral Home �o`e"'�`�' ❑°onation
<br />r±
<br />�
<br />�
<br />C17Y
<br />�PART 1 (� .. _. .. _.___..___. _.__-_. _. _. _•.___,-.. 1 ............._....,......,.........,....,,.....
<br />�� C W 'CJ}( �'7 �^ tCy c, `/i G c' j � l/+, J� l�`V� C.tu�
<br />DUE TO, OR AS A CONSEQUENCE OF: � �—� � � I
<br />. Imervai Uetween onset antl Oeain
<br />�
<br />. � .. � � . . . �i
<br />: ___ ...._._ ___ ______- � I
<br />DUE TO; OR AS A CONBEQUENCE OF: � � � � � � IMerval between onset and aeath
<br />�c` i
<br />- OTHER StGNIFICANT CONDfTIpNS • COnditiOnS ConblbNing W Me tleaM bul nW refated � PART 111 IF FEMALE. WAS THERE A� �/AU70FSY . WAS CASE AEFERRED TO MEDICAL �
<br />PART � � � PqEGNANCY W tHE PAST 3 MQNTHS? EXAMINER OR CORONEA7
<br />n
<br />� � � � (Ag057P54) Yes . No Yes No � Yes �No �
<br />.—_ __ __. . ._ _
<br />26a . � 28b. DA7E OF dNJUqY /MO.. Day. Ycf 26c. HOUR OF INJURY � 28d. �ESCRIBE HOW INJURY pCCURREO � �
<br />� ACCiyent � UadeterminBE . . M , . �
<br />� Suicide � PenGng � 26e, INJURY AT WORK 26�, �e bufltlir�g,yeM Y f�o1P9, tarm. sireet: (aCtory 26g: LOCATION. STREET OR R.F.D. NO. � CITY OR TOWN " STATE
<br />L_.i � � nlf . . .
<br />� NomiCWe 1nveStgaUOn ygs No � � � �
<br />-_._,—____—.— -_ — _____. _
<br />2Te. DATE OF DEATH �/Mo.. pay. Yc) � � . . ?$a. OATE SlGNED /Mo_ Day. Yc) 28b. TIME OF �EAT4i .
<br />A � Q �
<br />� ` ` � a . . . . . . . r .. . ... . . . . �
<br />$ � . �. � : � : � . . M . ..
<br />� ..27Y. OATE S1GNE0 /Ma, Oay. Y�l �c. 71ME QF OEATH `a � 28c PApNOUNCEO DEAD JMo Day, Yy 28tl PRONOUNCEb�DEAO �/HOUr/
<br />� J�. � ,. .
<br />, � y 4 r `
<br />�.'2.�,�[1� ' ':, .lC'1ri' '., M �w��
<br />$� 2i� To Me best of my kfmwlgAge. Aeytli occurred at Me Gme date aM place aM tlue ro the °�° 28e. On the basis of examinaGOn andrw inveSUqation, in my upuqon tleeth occunetl at � � M
<br />� < causetsl stated. �.. ; � , � . .�. , _ � �- ���. � a .
<br />........__
<br />4V � J J � c� the time, da[e and ptace antl due to the cause(sJ stated
<br />� � . � . . _ ,_ . . __. .
<br />. . � ts rtatwe arW Title ► . �. . , �.: , �5 aawre and TiNe ► . . . . . _.. _ . .... � .. . . .. . . .
<br />� 010 Tp8ACC0 USE CONTRIBUTE t0 THE DEATN? �� NASqFIGAN Ofi TISSUE DQNA710N EEN CONSIDERE�? .b WAS CONSENT GRANSEO? �
<br />� � � YES � � NO ..� UNKNOWN .� . .. .. � � YES � �NO ,. � . . . � YES � NO . .
<br />---- ------- . . . . � �
<br />DATE FILED BV REGISTRAP
<br />EEB 3
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