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� -� <br />ti�n���'���41}E RA�SED SEAL OF THE NEBRA3KA HEALTH AND HUMAN 3ERVIC4� <br />BELOW TO BE A TRUE COPY OF THE OR/Q/NAL RI�C014D ONfILE W/TH <br />THE NEBRASKA HlCi4LTHAND HUMAN SERVICES SYSTEA� NTAL 3TAT/ST/__�_ JS <br />THE LEQAL DEPOSITORYFOR VITAL RECORD� �`" <br />-� � y= <br />oA� � �s�,A� 2 0110 2 2 9� �� _: <br />_ � �F, <br />S E P 2 3 1 9 9 9 �= �v� � R <br />20020094� �� � <br />uNCOUV, NeeRasKa rrea�ni <br />� �T <br />� STATE OF NEBRASKA- DEPARTA�1'f OF HEALTH AND HU�VI�GES FiNANCE 1 <br />VffAL STATISTlCS -�:- s- . -..�" , � � >; � <br />CERTIFICATE OF DEA� � � �3F �ti�: <br />1. DECEDENT-NAME FIRST MIDDIE LAST 2' `_ ��..., ..�j?,EATH <br />Carmen <br />///not h U.S.A.. nemB <br />S1oux City� To�wa <br />�CIAL SECURTIY NUMBER <br />479-40-8603 <br />�3 mi west of Wood River on <br />� a� Tnwu ea �_ocnr��N c� a�>*u <br />- Wood River <br />9a.RE51DENCE�-STATE � � � 90.�COUNTV <br />Neb�aslc� Hall <br />- tp. RACE -.�e.g., White; &eck Am <br />� ete.IlS <br />�.� <br />lda. USUALOCCUPATION /Gi� <br />� d workiig li/B. evBn ArolirBdl <br />�soe��M <br />i/70 ma4f <br />; Howard <br />-� 18. WAS DECEASED EVER IN U.S. ARMED fORCES? <br />= �Yes. no. or unk.� {• pl yes. give war url tlates W asrvkea) <br />1 t9a. <br />Garnet A. Phillips <br />- NAME . . � . . . . . .. . . . . . . . <br />'el Snc�.ratl r r <br />P. B 37 13 05 Walnut Stree� Wood River NE 68883 <br />. EMB MER - SIGNATURE 8 LICENSE NO .-��� 21 a. METMOD OF qgpOS�TqN 21b. DATE � � :.��� 21a CEI <br />' �� ❑ e�,.� ❑ �mo„e� Sept . 7 , 1999 � <br />� ATORY IOCAT10t� <br />2a. FUNEFALH -NAME �' � 21d. CEMETERVORCfiEM ..••�..• •-•��• -- -- <br />Apfel Funeral Home ����^�^ ❑�^ Gibbon, NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OH TpWN. STATE. ZlP) <br />I411 West 11th Street Wood River, N�; 68883 <br />_ 23. IMMEDIATE CAVSE � (ENTER ON�Y ONE CAUSE PER UNE FOR lal. Ib�. AND (tp � Mxerva� beiween a�eet aM aeam <br />PART � • <br />� �� multiple trauma ; minut � <br />� I IMerval Ee1vMln onaet eM Oeam <br />� DUE TO, OR AS A CONSEOUENCE OF� � <br />'� <br />� I : <br />I <br />� , oUE70.ORA5AC"vh,:;=•]� NC ",.. -�� . . -.-" . . - ' ' . . . , . -._. . �--:_. �,.�vht0ewenna'w��.n� ��. " . <br />� � W <br />��� i � d <br />PART OTHER SIGNIFICANT CONDITIONS • CpWitions conbibusng b the CeaN Dut not �elate0 pREGNANCY N E PAST 3 MONTHS? 2�. AUTOPSV 25. EX S R� ED TO MEDICAI � <br />� <br />II <br />. (pges 10-541 Ves No Vss No Yes Y No <br />26a. 28b. DATE OF INJURY /Mn. Day. Yc) 28t. HOUR OF INJURY Z6d. DESCHIBE HOW�INJURY OCCURRED � <br />}�-a <br />�A������ ❑ �^��^� 9/5/99 2:30 .�,. automobile accident }-' <br />� Su�:itle � PerWing 28e. iNJURY AT WORN 261. PLACE OF �NJURV (�1t horM. term. Shea1. teCtory 2fig. LOCATION STREET Oii F.F.O. NO. GTY OR TOWN �STA7E - <br />olMCe Mnaairp. stc. SErec�•� <br />❑"°""°'ae '"°8g"�"°" `'°S❑ "°� highway Hi h�aa 30 Wood River -NE � <br />27a. DATE OF DEATH /Ma. Day. YcJ � �� � 28a. DATE SIONED /Ma. Osy. ».! 28b. TMAE OF DEATH � <br />��� �.�� 9/7/99 a rox 2:30 M <br />'� � t `'�, y 21b. DATE SIGNEO 1�.. �aY. YU � �� 27t. TIME OF DEATH ��� � . �. > 28c: PppNOUNCED DEAD /MO.. WY• Yr.l � � 2Bd. PRONOUNCED OEAD lhbwl .. <br />-8�� M �"�� 9/5/99 3:14 M <br />�� z�e. ro me ue� m my k�wneega. osam �cw�reo a� ms nnN, aa• a�o v�e ana ow ro me � zes. a, ms o..�a a«am�aear.�w�« n� ovp+ aw, a�m.w u <br />0 <br />r � " �,,,,�,,,� � a nb o�' e.a a�a a•oe.�e ° '� H a 11 C o. A t t <br />, ISi nature aed Tille � � . . _ .. _ . . � � � . . Si nWro uM Titla y <br />29. DID TOBACCO USE CON'fF18UTE TO THE DEATH4 �� � � 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ��A � WAS CON EO? . . .. <br />� YES � NO .� UNKNOWN � � �ES � NO � YES O NO <br />3t. NAME AN� ADORESS OF CERTIFIFA �PHVSICIAN, CORONER'S PHYSICVIN OR COUN7Y ATTORNEYI lTyps a Pnnp .� � �� �� � � � <br />Ellen L. Totzke, Hall County Attorney, PO Box 367, Grand Island NE <br />32a. RE6ISTRAR � � 32D. OATE FlIED BV REOISTRAR ��iUa. D�y. YrJ <br />�..�/,.�r SEP 101999 <br />lores Sc] <br />5a. nGE - Last Binhd� <br />IYrs.I <br />61 <br />ea. <br />Sb. MOS. ' <br />I <br />� <br />reeq <br />HOSPRAL: � lnpadaM OTHER: � Nuraing Mome . <br />� ER ONp�SM � RNiOence � <br />30 ❑ �� � �,,,,,��est of Wood River <br />ee. w�o� cm iu,+iT� ?e. e!+!wrv oF osaTH . <br />�Y..[]N�(� Hall_ __.. <br />9t. CITV.TOWNOfiIOCATION � 90. STREETANDNUMBER lMckpWgZ'pCOds/ 9e.tNSIDECITVLIMITS <br />Wood River 1305 Walnut Street �,� 0 N , ❑ <br />Ilalian. Mexitan. German. etcl 12. r} MARRIED a WIDOWED � 13. NAME OF SPOUSE !M wde. grve mNdan nsmo) <br />�o <br />l lst, NEVER pIVORCED �irrel Schwaderer <br />�� <br />16b. KIND Of BUSINESS INOUSTFiY 15. EDUCATION (SpKAY �Y �� ��� <br />Ebmenlarv a SseorMdrv 10-t21 � Cdb9e n-a a 5-� . <br />R. Mills <br />