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STATE OF NEBRASKA
<br />' � WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH�kAlT9��UlyA��,E VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�Y D�P,4,R�7M�IL�T�ry�F AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �a ��2EE' f r y � �, x
<br />� �"�, �,��I��' c ����� ,
<br />DATE OF ISSUANCE a �, ;� a o��7'�! -': °�°
<br />� S7`�AI�EY S. �O ER , ;, ; ; � ;�
<br />AUG � fi0 ZO�� � � �, �,i� � !"il V �i � A5'�I67�INT�T��,�G ST�R'' � ,�.�. .
<br />D��'A�TMENT OF HEAL�Al1[i7� .
<br />LINCOLN NE'BRASKA � � HUA�IR��SER�/ICES ` r : "Y� ;�'
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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN[] SUP 01� s ' `' � a
<br />�'��, CERTIFIGATE OF DEATH �.� �'� 3 4 4
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<br />1.�ECEDENT'S•NAME (Firet, Mlddis, Leat, 6uNlx)' 2.SEX 3.DA7EOFOEATn(ma,oay,rr.�
<br />Dianne Rose Clark Female November 9, 2008
<br />d. CITY AND 3TATE ORTERflRORY, OR FOREIpN COUNTRY OF BIRTH 8a.A0E•Lflet Birthdfly 66. UNDEFi 1 YEAfl 6c. UNOER t DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yre.) MOS. DAYB HOURS MIN9.
<br />. Hd.sti�g��;• Nebrsatca . 71 August 12, 1937
<br />7.SOCIALSECURI7YWUMBER ' BaPLACEOFpEATH
<br />505-44-3579 yQSeLTAL: 0 Inpapant Q� ❑ NuwingFiomelLTC ❑HoaplceFacUBy
<br />Bb. FACILITY-NAME Qf not Instltutlon, glva slreet end number} ,
<br />❑ EAlOutpetleM l�[�ecedeM'eHome
<br />208 E. Plum St. 0 ooa Oaner(eP�y?
<br />BaCITY.ORTOWNOFDEATH (IncludeapCode) 8d.00UNTY0FDEATH
<br />Doniphan 68832 ' IIall
<br />9aRE31DENCEBUTE 9b.00UNtt �. CITYORTOWN
<br />Nebraska Hall Doniphan
<br />9tl.8TREETANDNUMBER 9e.APT.NO 9t.ZIPCODE 9g.IN91DECITYLIMR3
<br />208 E. P1um St. ' 68832 4� ves ❑ No
<br />10a. MARITAL STATUS ATTIb1E OF DEATH �1 Menied Q Never Married 10b. NAME OF 8POU3E (First, Mlddle, Laet, 9ufilzJ It wHe, give malden name.
<br />❑ Mertlad, but seperated 0 Widuwed ❑ Dhroroed ❑ Unknown
<br />James Gerald Clark
<br />11. FATHER'6•NAME .(Fhet, Middle, Last, 8ultixj . 12. MOTHER'3-NAA9E (First, � M11lddle, Maldan 3umame)
<br />Albert Maul Rose ' Cloe. Varah
<br />13. EYER IN U.& ARMEU FORCE$? Oive d'atas of servlce U yea. 1da. INFORhAANT•NAME 14h. RELATIONSHIP TO DECE�ENT
<br />(Yes,no,orunk.) NO JSIIt@S G Clark Husband
<br />18. ME7HOD OF DISP081TION 18e. EMBALMERSIGNATURE iSb. UCENSE N0. 780. OATE (Mo., Day, Yr. )
<br />ae���i ❑o�ation Not Em.balmed November 10 2008
<br />QCremaHon ❑Entombment 16d.CEMETERY,CREMAT0AY0ROTHEHLOCATION C�TY/TOWN 6TATE
<br />� OHemavel ❑oma��s,�mry� � �estlawn Memorial Park Crematory 'Grand Is�.and,� NE
<br />17a FUNERAL HOME NAPdE AND MAILINa AODRE9S (61reet, Clty orTawn, 6tate) 17b. Zip Code
<br />Liningaton-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, NE 68803
<br />1& PAqT I. Enter ihe chaln ol events-dlseaees, InJuriea, or complloaUans-that dlreatly oaused the death. DO NOT entar terminal evenie such ea cerdleo errest, ' APPROXIMATE INTEHYAL
<br />I
<br />reephatory arrest, orvenMcularflbAUadon without ehoming tlte etio�apy. QO N0T ABBREVIATE. Enler oNy one ceues on e Iina, Add eddiUonet Ilnea fl rtecassary. i ��.
<br />k�Jm� � i �
<br />�tMED1ATECAU$E(Fllml ' � � ' �
<br />���� �wA DUE T0, 3 A NSEQUENCE OF: I onaet �o dseth 10
<br />tnd�IM) j� I ��/ � Wcy �� G'"'
<br />8equ�UaUyllstcmMltlons�lf ro� J�"fM�' � `+� " Ld V
<br />����t DUETO,OAABACON6E�UENCEOF: � . I oneattodealh
<br />onlhrea 1
<br />E�tltaUNDERLYINaCAUBB 1
<br />id(aeaworinl�ry�N�deted ��T i
<br />������� DUETO,OqABACON9EQUHN6E0F: i oneetWdeeth
<br />1A31' �
<br />�d! {
<br />18, PAR711. OTHER SIONIFICANT GON01TI6N9�COnditlona comrihuUnp N tfre deeth but rrot resulting in ihe underlying aeuee gNen in PAHT I. 98. WAS MEDICAL E%AMINER
<br />ORCORONHRCO ED7
<br />❑ YE8 NO
<br />20.IyFEMALE: 21aMAyaEROFDEATH 214.IFTRANSPORTATIONINJURY 21c.WA8ANAUTOP9YPERFORMED9
<br />��7 pregnant uvlthin pest year .� t'lNeturel C] Homlada ❑ Driver/Operetor
<br />❑ Pregnani at Gme of death ❑ Acaident0 Penping ImreaUgaUon
<br />❑ Pesse�er O YE8 0
<br />0 PedesMen
<br />I� Nolpregnant,butptegnenlwlWn42dayeoldeath 27d.WEREAUTOP9YFINDW�9AVAILABLETO
<br />❑&ulcide ❑ Cauld not be determined p Other (Specify)
<br />❑ Notpregnant,butpre�ant43dayatviyearbeloradeath � COMPLETECAU9EOFDEATH4
<br />❑ llnknomm If pregnant taiNin the pest year . � ❑ YES y{m0
<br />Z2a. DATB OF INJURY {Mo., Day, Yr.J ZZt. TIME OF INJURY 22c. PLACE OF INJURY At bome, term, streal, fflclory, omce huliding, conatruclion eite, etc, �3peaityJ
<br />m
<br />22d.INJURYATWORK7 22e.DESCflIBEHOWIN,lURYOCCUHREO
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJUAY • STREET & NUMBER, AP1: NQ C11YlfOWN
<br />SWE ZIPCODE
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<br />DATE OF �EATH (Ma, Day, Yt.) 24a. DATE SIONED (Mo., Day, Yr.) 24b.TIME OF DEA7H
<br />�vember 9, 2008 y� � m
<br />DATE 6NED ( o Day, 29c.T4ME0FDEATH 24c.PftONOUNCED0EA0 (Mo.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />vem�er �.Cl ���08 k 9: 30 W a� m
<br />T Ihe basi ol &nowledge dee occurted a! ihe Ume, date and plece �� 24e. On the baels ot exeminetlon and/or Imeadgation, in my opinion daeth xourcetl at
<br />nd due to t {a) etafetl. Igneture end Tipe ) � .� p the 1ime, dete and place end dua to Ihe aause(ay eteted. (Signalure ertd Titla }♦
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<br />U CONTRIBUTETOTHED 4 28a. HA8 OR�AN OR TISSUE DONATION BEEN CONBIDERE04 286. WAS CON5ENT �RANTED7
<br />� NO ❑ PROBABLY ❑ UNKNOWN 0 YE8 �NO . Nol Appllaable it29a la NO O Ye9 ❑ NO
<br />28a RE6I5TPAR'3 9IqNATURE
<br />ITIFIER (PHY3ICIAN, C
<br />.D. 800
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<br />NE 68803
<br />1 28b. DATE flLED BY REQI97pAR (Ma, Day, Yr.)
<br />Nov x °s,2orn
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