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<br />Lots Fifteen (15), Sixteen (16), Seventeen (17), and Eighteen (18), in Block Four (4), in MacColl
<br />and Leflang's Addition to the Village of Wood River, Hall County, Nebraska.
<br />WIEN TINS COPY C MMES TIE RAISED SEAL OF THE NEBRASKA HEALTH AI P HUMAN SERVICES
<br />SYSTEM RCERTFES TIE BELOW TO BE A TRUE COPY OF THE ONGjNALAWXW&QVfijMAMW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST( $€ T{Q11 1Vhl %L: IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,
<br />A���
<br />DATE OF ISSUANCE
<br />�! � /A11iLL�Y� GOOP�t=
<br />MAY 12 2000 200105759
<br />A srirreAt"T
<br />LINCOLN, NEBRASKA HEALTH AND HEN SERVICES.SYMN:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER.VWjff FINAN£E $¢IgpORT
<br />VITAL STATISTICS s _
<br />("R.RTTFTrATTY (1R TWATL7 erJ
<br />1 DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH iMonm. Day Year/
<br />Glenn E. Barker
<br />Male '
<br />April 25, 2000
<br />4. CITY AND STATE OF BIRTH Moot in U SA name country)
<br />rr!
<br />UNDER 1 YEAR
<br />n
<br />r;
<br />So ..UNDER
<br />i DAYS
<br />o
<br />F-4
<br />Wood River, Nebraska
<br />(Yrs i 78
<br />4.
<br />co
<br />-inn
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<br />U
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<br />HOSPITAL LX.I Inpatient OTHER ❑ Nursng Home
<br />26t P�ACE QF INJURY - ppI home. farm street. factory
<br />- oaice building. etc /Specify)
<br />Q "I
<br />p
<br />St. Francis Med Center
<br />G
<br />r1
<br />S
<br />�gb
<br />9a RESIDENCE ST
<br />NE
<br />N
<br />co
<br />9tl STREET AN NUMBER rincl�mOgZip OC'ode)
<br />604 East St,
<br />9e INSIDE CITY LIMITS
<br />Yes K] No ❑
<br />10 RACE - (a g.. White. Black. American Ind -an
<br />eWl, 13686
<br />m
<br />12. MARRIED a WIDOWED
<br />NEVER DIVORCED
<br />^+ M
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<br />A
<br />Ln
<br />Elementar Secontlary i0 121 College 1 -a o,
<br />i
<br />16 FATHER NAME FIRST MIDDLE LAST
<br />Roy Barker
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Amanda Haack
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<br />Cn
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<br />28e. On the basis of exammaeon and or Investigation, :n my opinion death occurred at
<br />causes) stated
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<br />the time, date and piece and due to the cause(sl stated.
<br />!Signature and Title) ►
<br />ISI nature and Title)
<br />29. Dt0 TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />❑
<br />3D.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />r
<br />YES NO ❑ UNKNOWN
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<br />I,y�
<br />❑ YES 1 V1 NO
<br />"'-- -111
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) I type ov Print)
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<br />Lots Fifteen (15), Sixteen (16), Seventeen (17), and Eighteen (18), in Block Four (4), in MacColl
<br />and Leflang's Addition to the Village of Wood River, Hall County, Nebraska.
<br />WIEN TINS COPY C MMES TIE RAISED SEAL OF THE NEBRASKA HEALTH AI P HUMAN SERVICES
<br />SYSTEM RCERTFES TIE BELOW TO BE A TRUE COPY OF THE ONGjNALAWXW&QVfijMAMW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST( $€ T{Q11 1Vhl %L: IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,
<br />A���
<br />DATE OF ISSUANCE
<br />�! � /A11iLL�Y� GOOP�t=
<br />MAY 12 2000 200105759
<br />A srirreAt"T
<br />LINCOLN, NEBRASKA HEALTH AND HEN SERVICES.SYMN:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER.VWjff FINAN£E $¢IgpORT
<br />VITAL STATISTICS s _
<br />("R.RTTFTrATTY (1R TWATL7 erJ
<br />1 DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH iMonm. Day Year/
<br />Glenn E. Barker
<br />Male '
<br />April 25, 2000
<br />4. CITY AND STATE OF BIRTH Moot in U SA name country)
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH !Month. Day Yearl
<br />So ..UNDER
<br />i DAYS
<br />5c. HOURS MINS
<br />Wood River, Nebraska
<br />(Yrs i 78
<br />May 19, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />Be PLACE OF DEATH --
<br />508 -38 -2120
<br />n
<br />HOSPITAL LX.I Inpatient OTHER ❑ Nursng Home
<br />26t P�ACE QF INJURY - ppI home. farm street. factory
<br />- oaice building. etc /Specify)
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (n not ,nstltution, give street and number)
<br />St. Francis Med Center
<br />❑ DOA ❑ Other ISpec,ty
<br />Bc. CII'TY. TOWN OR LOCATION OF DEATH
<br />SO INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />�gb
<br />9a RESIDENCE ST
<br />NE
<br />COUNTY
<br />Hall
<br />9t CITY TOWN OR LOCATION —L
<br />Wood River
<br />9tl STREET AN NUMBER rincl�mOgZip OC'ode)
<br />604 East St,
<br />9e INSIDE CITY LIMITS
<br />Yes K] No ❑
<br />10 RACE - (a g.. White. Black. American Ind -an
<br />eWl, 13686
<br />11. ANCESTRY le.g.. Italian. Mexican. German, etcl
<br />(Specify) American
<br />12. MARRIED a WIDOWED
<br />NEVER DIVORCED
<br />13 NAME OF SPOUSE i/t.de. give maiden name/
<br />Mary Ellen Reeder
<br />working /ire, even d retired)
<br />14a USUAL OCCUPATION /Give kind of work don. during most J41exvice
<br />ervice Tank Driver
<br />OF BUSINESS INDUSTRY
<br />Station
<br />15. EDUCATION (Spenry omy Highest grade completed)
<br />Elementar Secontlary i0 121 College 1 -a o,
<br />i
<br />16 FATHER NAME FIRST MIDDLE LAST
<br />Roy Barker
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Amanda Haack
<br />(Yes no or unk.) I III yes give war and dates of services)
<br />N Mary Ellen Barker _
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.O NO.. CITY OR TOWN. STATE. ZIP)
<br />604,tEast st Wood River, NE 68883
<br />:'0 E BA E SIGNATURE B 21a METHOD OF DISPOSITION L1b. DATE 21c CEMETERY OR CREMATORY NAME
<br />Ar Aril 28 2000 Wood River Cemetery
<br />� Burial ❑ Removal �- ___ —_
<br />22a F E NAME 2rd. CEMETERY CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Aptei Funeral Home ❑ Cremation ❑ Oonil Wood River, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F D. NO CITY OR TOWN. STATE, ZIP; -- - - - --
<br />411 West 11th St P.O. Box 126 Wood River, Nebraska 68883 _
<br />23 IMMEDIATE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl. AND Icll Interval tween onset anr, oeai _
<br />. PART
<br />Ial
<br />~ DUE TO.OR A CONSEQUENCE OF —
<br />Interval between onset and oem,
<br />DIL v/�
<br />DUE TO OR AS A C S OUENCE OF Interval between onset and dean
<br />i
<br />OTHER SIGNIFICANT CONDITIONS Contlrtlons contributing tote death but not related PART III IF FEMALE. WAS THERE A
<br />PART
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />,� A A PREGNANCY IN THE PAST 3 MONTHS'
<br />II I'CN
<br />EXAMINER OR CORONER'
<br />C�_ (Ages 1054) Yes No
<br />Y95 No
<br />Yes [] No
<br />26a
<br />26b DATE OF INJURY /MO.. ay. YrJ
<br />26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED s
<br />El Accident F] Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26t P�ACE QF INJURY - ppI home. farm street. factory
<br />- oaice building. etc /Specify)
<br />26g. LOCATION STREET OR R F.D. NO CITY OR TOWN STATE
<br />Homcide Investigation
<br />Yes No
<br />❑ ❑
<br />27a DATE OF DEATH (Mo Day Yr.)
<br />28a DATE SIGNED (Mo. Day Yr)
<br />28b. TIME OF DEATH
<br />27b DATE SIGNED /MO Day Yr;
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD (MO_ Day, Yc!
<br />28tl. PRONOUNCED DEAD (HOUrI
<br />}
<br />r c Y
<br />$
<br />°
<br />27d To the best of my knowledge d cu d at the time, date and place and due to the
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<br />28e. On the basis of exammaeon and or Investigation, :n my opinion death occurred at
<br />causes) stated
<br />K
<br />the time, date and piece and due to the cause(sl stated.
<br />!Signature and Title) ►
<br />ISI nature and Title)
<br />29. Dt0 TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />❑
<br />3D.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />r
<br />YES NO ❑ UNKNOWN
<br />YES 1(I NO
<br />I,y�
<br />❑ YES 1 V1 NO
<br />"'-- -111
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) I type ov Print)
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