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. STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECgROzO tAU WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S7AT1St1C$4#&_M I,,WHm IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />13 <br />20 <br />APR 0 3 2007 <br />561 4 TS'FA <br />ASSISTANTS 'FA <br />201102 <br />LINCOLN, NEBRASKA <br />HEALTF.4N[3 HU9/AR'SERV <br />STATE Of NWASKA•MAJLnIBt?i.CEMM.'>x1ANDMWSUVKES ,81~i-Std. <br />VITAL STATISM <br />CERTIFICATE OF DEATH' <br />+ DECOENT-NAVE FIRST <br />- MIDDLE LAST <br />I Sex 3 w DEATH '41ILw.e•.-1 Year, <br />Hilda <br />Mark Chamberlin <br />Female April 24, 2*4 <br />A UTV ANDSTATE OF SRI. rrptn USA A&MOMaWy, <br />SA AOC -LAM BwemaY UNOER I YEAR <br />UNDER I OAV 0 DATE OF OMIT- :MOCK DV. v« <br />Brand, Arkansas <br />rrnr 75 so Moe DAYS <br />x Houta wNS Jame 30,1!28 <br />T yFR~t +1~M'tBE,R <br />7J1 <br />IN, PLACEOFDEATH <br />V <br />-SpTk ❑yMy OTHER Nviw.q Hone <br />Np FACILITY -Nerve (arXw.gaa4a/L pN aaearaw ry.waay <br />❑ ER OukMbW ❑ Rauawx* <br />TWmy Share Cars Center <br />❑ ODA ❑ cam. , <br />Nebraska ;Ran <br />nw.--~ wlpVl 111 ANGESTRYte9 <br />Wdft"t 1 mw* m <br />a USUAL OCCUPATION ,6- twd W w** dq l"mw <br />-Mqw- <br />FATHEP-NAME FIRST MIDDLE <br />Ernest L <br />WAS DECEASED EVEN w US ARMED FORa$ <br />I~n? a art I ~ w rat arw Aar tro awns of tDAIVCAt~ <br />b INSIDE CITY LIMITS M COUNTY OF DEATH <br />Yet NO ❑ Han _ <br />I IN <br />CITY TOWN OR LOCATION 91 STREET AND NUMBER AvA,*WZv Coen j 9e INSIDE CRY LMM(S <br />Grand bland 1908 W lot St., 68803 ~ yes ❑ <br />n.Mpkall,Oo+nan, aw:i tT MARfeEB ❑WIDOWEO t3 NAME Melvin rM rlle ywe_nwrOr`n n.M.ArFtI_ <br />NEVER DIVORCED Melvin Mtht Charbaft <br />F146 KIND OF k*"SS INDUSTRV - 15 EDUCATION (Spttl~F orwF wnplSyy) <br />own Rome I E4112Mq a, SACmmarr +0 121 Colept 11 .4 of s•I <br />LAST I? MOTHER FIRST MIDDLE MAIDEN SURINAME <br />Diskson Etta May Phillips <br />191 WORMANT•NAME <br />Metvm Diot Chamberlin <br />1908 W Ist St, Grand Island, Nebraska 68803 <br />20 EMBALMER • SIGNATUAE a ILICEN E NO 21a METHW OF OISFDSITKIN 2tb. DATE 21C CEMETERY.OR CREMATORY. NAME <br />, ~r n,a 12M ~ eWw ❑ "18"0" Mason City Cemetery <br />22a FUNERµ - ME 210 CEMETERY ON CREMATORY LOCATION CITY OR TOWN STATE <br />Kkme now GMwaA D,, Masoe City, Nebraska <br />22E FUNERAL NOME ADDRESS (STREET OR R F D NO. CITY OR TOWN STATE . 2" <br />3213 W North Fralt St Grand Island, NE, 68803 <br />23 PART IMMEOIATE CAUSE CENTER ONLY ONE CAUSE PER LINE FOR Iai 101. AND ICII ww&vai "m" mm and 0eaw, <br />;a. <br />';Lt rl i MAAO Nwu~ <br />DUE TO OR AS A CONSEQUENCE OF wtVvM bellNaeA 0r111411 am 0eam <br />ID) <br />DUE TO OR AS A CONSEQUENCE OF Vovl r haw W_ GneM ano 09W <br />itl <br />PART OTHER SIONWICANT CONDITIONS - Owal&%C0nwOWp to ww math but not moved PART W IF FEMALE WAS THERE A ?a AUTOPSY 2S WAS CASE REFERRED TO 1EDICAL <br />w RAwE, er-N'_- A.- It-. , PREGNANCY IN THE PAST 3 MO INS, EYAUwaQmrvk-.w_ <br />❑ ACCXWV ❑ Vrw)Nar, <br />❑ Homc,ea ~9+~^ <br />A! <br />o~ <br />~r --.._---_--_-..-Y,,.._ ..............R-_aw.e..e.• ~auewwsLAN5E1NTORANTED7 <br />❑ YES !YI NO ❑ UNKNOWN ❑ YES NO ❑ YES NO <br />31 NAME AND ADDRESS OF CERTIFIEM PHYSICUN CORONER S "SICNN OR COUNTY ATTORNEVI ?IM*,v mWN <br />Anne K. Morse, M.D., 729 N Custer Ave _ . aranrl Tat mnA WT1'1. acano <br />