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'�U11U5164 <br />WHEN TH/S COPY CARRIES TNE'RAISED SEAL OF Tf�liE NEBRASKA 1'�IEALTH AND HlIMAN SFRV/CES • <br />SYSTEA� IT t�R1lF1ES THF BELOW TO BE A TRUE COPY OF THE ORIG/AIAL RECORD OAFFILE WITH <br />THE NEBR�SKA HEALTH AIYD �HUMAN SERV/CES SYSTEM, V/TAL STA�OST/CS 3tECZf�A� WHICH IS <br />� THE LEQAL DEPOSITORY FOR V1TAL RECORDS =- =_ <br />DATE OF /3SUANCE � j�� `^"8 � <br />������ Ct90�ER <br />�IIAR 2 9 200� Ass�sraNrsrar��GESrr�aR <br />LINCOLN, NEBRASKA HEALTH Allit,� OiUMAN SERVICES SYSYEM <br />� STATE OF NEBRASKA- DEPARTN�NT OF HEALTH AND HUMt4N SERVICES�F@�IANCE AI�[D SUP RT <br />ViTAL STATISIICS � � V � � V � <br />CERTIFICATE OF DEATH - <br />t. DECEDENT - NAME FIRST MIDDLE � LASi 2. SEX d DATE OF DEATH /Month. Dav. Vear1 <br />Wallace G�.ee Davis Male� March 9 2001 <br />4. CITY AND 57ATE OF 81RTH ll/rtof rn USA., name camlryJ 5a. AGE - Last BiMday � . UNDEp t YEAR UNDER t DAY 6. DATE OF BIRTH /Mon&, Day. YearJ <br />Shelby, Nebraska �'�� 76 Sb.MOS. i oAYS Sc.HWRS ��NS. November 1 9, 1 924 <br />7. SOCIAL SECURTIV NUMBER � � 82. PLqCE OF DEATH <br />5 41- 2 2- 4 2 6 3 �PR� ❑���Ue� OTHER: � N� �e <br />8b. FACILITY - Name /!lrwt nrstifution, give sheet and number/ � ER Oufpauetn � Residertce <br />Howard Count Hos ital � °OA � Oth eir s �''y' <br />Bc. CITY TOWN OR LOCATION OF DEATH � , Bd. INSIDE CITY UM1TS 8e. COUNTY OF DEATH <br />St. Paul - Y� � ^� ❑ Howard - - <br />9a. RESlDENCE - STA7E 9b. COUNTY ..� 9c. CITV. TOWN OR LOCATION � 9tl. STREET AND NUMBER prtdud'rrtg2ip Cotle) 9e. INSIDE CITV LIMITS <br />Nebraska Merrick Palmer 806 N. Stanwick 6886 Y� Q No❑ <br />t0. RACE - �e.g.. white. BWCk. Ameriean Indian. 11. ANCESTRY (e.g.. itaDan, Mexican, German, etcl t2 O MARRIE� ❑ WIDOWED 13. NAME OF SPOUSE /il wi/e. g'rve maiden namel <br />etalJ$qeclte . (��.1 'sh/Irish ❑ M RRRD DIVORCED Maxine Meyer <br />WIl <br />14a�USUALOCCUPATION lG�vekiMnlworkdonetlmirtgrttost t4b. KINDOFBUSWESSINDUSTRY 15. EDUCA7IQN (Speaty4niyhighestg�etlacompleted) � <br />� o7xrorkmg life, even Brehred1 � Elementary or Secondary 10-72� ' Coliege It -4 or 5-� <br />Heavy Equipment Owner/Operator <br />16. FATHER • NAME F(FtST MIDOLE LAST 17. MOTHER FiRST MIDDL MAIDEN SURNAME <br />� T v <br />1& WAS DECEASED EVERIN US.ARMED FORCES? 19a. WFORMANT-NAME - � <br />�Yes n or unk i I � Iif yes. g�ve war arid da�es G serviCeSJ -� <br />Yes�t 4 5- <br />19b. INFORMANT AI I G ADORESS . -" ISTREET OR 0.F.D. NO., CITV OR TOWN. STATE, ZIP) ,_, ,, _. _. <br />20.�EtaB ER-SiG 7uRE UCENS NO. -. . 2ta. 06F�4SPOStTtON � tbiDATE 2ta CEMET6RYORCREMA70RY �NAME <br />�]8��� ❑��,�,e� 3-14-2007 Rose Hill <br />�� FUNE E� NA E - �� � 27tl. CEMETERY OR CAEMATORV LOCATION CITV OR TOWN STATE <br />palmer Funeral Homes Inc. ��'�°°" �°°^a"�' Palmer Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CIIY OR TOWN. STATE, ZIP) <br />P O Bax 84, Palmer� Nebraska 68864 _ <br />23. IMMEOIATE CAUSE �ENTER ONLY ONE CAUSE PER UNE FOR 1a61b�. AND Iql � 1nIervai benveen w�set ana oeam <br />AAR7 • / � <br />� S 1 rG�.`�fl <br />lai � i <br />DUE T0. OR AS A C NSEQUENCE OF �� Intmvel bBNreen onSeFantl Ceatn <br />_ @� �Q � ' ( rr1 tL..i Ll.✓� Ji' 'CJ� ��� �U/ . � .. <br />DUE T0. OR qSA CONSE�UENCE OF� - _, . _ � InigrK@I between 9n5etantl qeatn <br />. . _ _ - _ �_ . . <br />I <br />(q i <br />OTHER SIGNIFICANT CONDITIONS - Cond'NOns ContribUdng to tliB deeth bul � tBlated PART tl� �F FEMALE. WAS THERE A 2d AUTOPSV 25. WAS CASE qEFERRED TO MEOlCAL <br />PART PREGNANCY IN THE PAST 3 MONTHS7 DCAMINER OR CARONER? <br />� � ��,,-� - �Ages 7Q-54� Yes � Na Ves No Yes NO <br />- 26a. � 28b. DATE OF IWURY /Mp.. Dey, Yr.J 26c. HWR OF IWURY 26d. DESCRtBE HOW INJURY OCCURRED <br />❑ AC � UMJetermined �'�� ' v\ (�\y�X,`A 1+1.t�� M �J @� t l�/l 1\ U-h Sh uS <br />�G cc <br />Swcitle � Pena��+g 26e. INJURY A7 WOHK 26f. P�ACE OF INJUAY •�.mP, farm, sireet lactmy 26g. LOCATION STREET OR ..D. N0. CIN OR TOWN S7ATE <br />❑ ce building, etc. / Qy �} <br />Homicide InvesGgation Y ��.� � � rn � � O� n1 ,. G,� ���\ � f" �\.��� N� <br />1v `✓ � Y <br />�� 27a. DATE OF OEATH (M1AO.. Day. Yr.J . 28e. DATE S16NED (MO.. Oay. v J 28D, 71ME OF OEATH <br />= h Zooz s M <br />� ��i3 0 27b. DATE $IGNED IMa. D y. r/ � 27C, TIME OF DFpTH ��� 0 29c. PRONOUNCED DEAD fHfa.. 08y, Yr.l 20d• PRONOUNCED DEAD (HOU�! - <br />��_ �/, � � �� �z4� _ <br />F� - M� �i� -:. M <br />27tl. TO Ihe best ot my kn de rr ihe tlme, date aiM Cue N fhe °�� 28e. On Ne besa 01 Bzammatlon and�w invesligation, in my opimon tleath accurted az <br />, ceuselSl stated. ~� °� �► the time. dale and plaqe antl due to tlre cause(sl Slated. <br />(S naNre aiM Tille) ' (S' naWre arM TRte <br />� 29. DIO TOBACCD USE CDNTRIBU 0 THE DEATH? � � 30.a HAS ORGAN OR TI$SUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br />I . � VES � NO �UNKNOWN � �� YES ` �� � YES �O' <br />31. NAME AND ADDRES$ OF CEflT1FIFA - fPHYSICIAN, CARONERS PHYS�CWV OR COUNTY ATTORNEY� /TypeOrPriMl � <br />��a�;=\ �1���v�.1�;�1 m. �'� a x �vs �S� �m�.l, lv€ c����3 <br />32a. REGISTRAR � 32b. DATE FILED 8Y� REGISTRAR /Mo_ Day. Yr.J <br />� � .�m� . MAR 2 8 2001 <br />�3 U - <br />