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1. DECEDENT - NAME FIRST MIDDLE LAST
<br />o _
<br />3. DATE OF DEATH (AIon h, Day, YON)
<br />CD.
<br />Male
<br />I March 10, 1992
<br />M ar
<br />M
<br />M
<br />N
<br />T
<br />6. DATE OF BIRTH (MAIM. Day. Year)
<br />-n M Fall
<br />Ap
<br />Sc. HOURSi MHVS.
<br />oa
<br />CD
<br />(Yrs.l
<br />41
<br />Aril 5, 1950
<br />�
<br />�
<br />'*1
<br />506 -68 -2058
<br />60. FACILITY - Name (M not irofiftOM gne eaeat and mrmaar)
<br />(R(B�I = T p
<br />-0
<br />7f
<br />= tin
<br />):;w co
<br />O
<br />p
<br />VA
<br />C \
<br />Irn
<br />a
<br />U-1
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Mchift Dp CoWI
<br />Be. INSIDE CITY LIMITS
<br />(Spoco/ Yes or No)
<br />1
<br />Nebraska
<br />Hall
<br />fit,,
<br />412 West 3rd 68810
<br />Yes
<br />CAD
<br />CD
<br />13. NAME OF SPOUSE (9 Ivy give maiden namal
<br />-
<br />111,
<br />White
<br />(Scotch /Irish O� Married
<br />Verna Rae Krolikowski
<br />14a. USUAL OCCUPATION (Gtm kind of wwa done damp most 14b.
<br />Of wonrNq tat even if reared)
<br />R
<br />ENnfanfary ar Secondary (0 -121 I COW" 0 -4 or 5•)
<br />a
<br />y
<br />2
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />117.
<br />Robert Clampitt
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES? 19.
<br />moo_
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO -BL'' ,WY
<br />Verna Rae Clampitt, 412 West 3rd, Alda, Ne 68810
<br />20a BURIAL, Crematon,Rstnovel,
<br />c'
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE D)l
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />March 14 1992
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGA,'I'0
<br />Grand Island Nebraska
<br />21. EMBALMS - SIGNATURE 8 LICENSE NO.
<br />22. FUNERAL HOME - NAME AND ADDRESS ISTREET OR R.F.D. NO., CITY OR TON(y„$TATE,j.�� 1
<br />1 Ojjtf(ISLAND
<br />VITAL RECORDS.
<br />LIVINGSTON- SONDERMANN FH, 505 W KOENIG, GRAND
<br />SE �NTER ONNLLLY ONE CAUSE PER LINE FOR Is), (b), AND Ic)) Intmal belwee^ onset and death
<br />V*AMED-IATE
<br />A C NCE OF: �mal men of and tfaaN
<br />DATE OF ISSUANCE
<br />OTHER SIGNIFICANT CONDITIONS Coroeions OonVibuting t0 death W rot (OWW
<br />PART W IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />(SWcs Yes or No)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER CORONER?
<br />MAR 23 199E
<br />q 0 0 q� C 1 7'3 STANLEY '���� E
<br />�G �Gr s! PER I
<br />Yes
<br />o
<br />(SOecdy Yes a ft) NO
<br />2" ACCIDENT. SUICIDE, HOMICIDE, UNDET.,
<br />LINCOLN, NEBRASKA±
<br />BUREAU OF
<br />DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Seedy)
<br />STATE OF NEBRASKA - OWARTMENT OF HEAL* -
<br />26s. INJURY AT WORK 261.
<br />PLACE OF INJURY - Al home, farm. sti". tacbry,
<br />25g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(Specify Yes or No)
<br />BUREAU OF VITAL STATISTICS
<br />Y
<br />27s. DATE OF DEATH (Ado., Day. Yr.)
<br />CERTIFICATE OF DEATH _
<br />26b. TIME OF DEATH
<br />March 10, 1992
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX - --
<br />3. DATE OF DEATH (AIon h, Day, YON)
<br />James G Clam itt
<br />Male
<br />I March 10, 1992
<br />1 4, CITY AND STATE OF BIRTH (M rot in U.SA, name cwmay)
<br />5a. AGE - Last BfrlMay
<br />5070S
<br />6. DATE OF BIRTH (MAIM. Day. Year)
<br />DAYS
<br />Sc. HOURSi MHVS.
<br />Grand Island, Nebraska
<br />(Yrs.l
<br />41
<br />Aril 5, 1950
<br />7. SOCIAL- SECURITY NUMBER
<br />9a. PLACE OF DEATH
<br />- HOSPITAL: 9IhWOatir G ERrOulpatiem G DOA ,
<br />506 -68 -2058
<br />\ OTHER G Numg Hem, G Residence G Down (spear)
<br />60. FACILITY - Name (M not irofiftOM gne eaeat and mrmaar)
<br />Bc. CITY, TOWN OR LOCATION OF DEATH
<br />-
<br />I
<br />ad. INSIDE CITY UIMITS
<br />(Spft* Yea or Not
<br />I
<br />N. COUNTY OF DEATH
<br />Bryan Memorial Hospital
<br />Lincoln
<br />Yes
<br />Lancaster
<br />Be. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Mchift Dp CoWI
<br />Be. INSIDE CITY LIMITS
<br />(Spoco/ Yes or No)
<br />1
<br />Nebraska
<br />Hall
<br />Alda
<br />412 West 3rd 68810
<br />Yes
<br />10. RACE - le.g. Wnee, Black, American Intlian.
<br />ANCESTRY (e.B.Julian. Mexican, German, W.) l2. MARRIED.NEVER MARRIED,
<br />WIDOWED. DIVORCED (Spactyl
<br />13. NAME OF SPOUSE (9 Ivy give maiden namal
<br />-
<br />111,
<br />White
<br />(Scotch /Irish O� Married
<br />Verna Rae Krolikowski
<br />14a. USUAL OCCUPATION (Gtm kind of wwa done damp most 14b.
<br />Of wonrNq tat even if reared)
<br />KIND OF BUSINESS INDUSTRY
<br />pN\
<br />ENnfanfary ar Secondary (0 -121 I COW" 0 -4 or 5•)
<br />Farmin `-�
<br />Livestock
<br />2
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />117.
<br />Robert Clampitt
<br />Jane Brown
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES? 19.
<br />INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. DPI
<br />(Yes, no, or unit.) IN yes, give war and does d "men)
<br />No
<br />Verna Rae Clampitt, 412 West 3rd, Alda, Ne 68810
<br />20a BURIAL, Crematon,Rstnovel,
<br />2W. DATE
<br />200. CEMETERY OR CREMATORY - NAME 200.
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />March 14 1992
<br />Grand Island C.j,.tL Cemeteryl
<br />Grand Island Nebraska
<br />21. EMBALMS - SIGNATURE 8 LICENSE NO.
<br />22. FUNERAL HOME - NAME AND ADDRESS ISTREET OR R.F.D. NO., CITY OR TON(y„$TATE,j.�� 1
<br />1 Ojjtf(ISLAND
<br />Z62q
<br />LIVINGSTON- SONDERMANN FH, 505 W KOENIG, GRAND
<br />SE �NTER ONNLLLY ONE CAUSE PER LINE FOR Is), (b), AND Ic)) Intmal belwee^ onset and death
<br />V*AMED-IATE
<br />A C NCE OF: �mal men of and tfaaN
<br />A CONSEQUENCE-OF: t Inhimal between onset and death
<br />I _
<br />OTHER SIGNIFICANT CONDITIONS Coroeions OonVibuting t0 death W rot (OWW
<br />PART W IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />(SWcs Yes or No)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER CORONER?
<br />PAT s
<br />II
<br />124.
<br />Yes G NO ❑
<br />Yes
<br />o
<br />(SOecdy Yes a ft) NO
<br />2" ACCIDENT. SUICIDE, HOMICIDE, UNDET.,
<br />M. DATE OF INJURY (MO..Day. Yr,)
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Seedy)
<br />126d.
<br />26s. INJURY AT WORK 261.
<br />PLACE OF INJURY - Al home, farm. sti". tacbry,
<br />25g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(Specify Yes or No)
<br />office building. M. (Specify)
<br />27s. DATE OF DEATH (Ado., Day. Yr.)
<br />28a. DATE SIGNED (Mo., Day. Yr.)
<br />26b. TIME OF DEATH
<br />March 10, 1992
<br />a
<br />S
<br />� <
<br />27D. DATE SIGNED (MO.. Day. Yr.l
<br />27c. TIME OF DEATH
<br />2BC. PRONOUNCED DEAD (Mo.. Day. Yr)
<br />280. PRONOUNCED DEAD (Flow)
<br />March 11, 1992
<br />1 2154
<br />i
<br />0. To the of my kno occurred at the time. date and place and due 10
<br />26e. On the basis of examination and,or investigation, in my opinion death Occurred at
<br />,"
<br />elsl satin
<br />tne time. date and place and due to hie eauss(+) staled
<br />and Title / 21
<br />nature and Tote
<br />2Ba. DID TOBACCO USE CONTV9yrOWE DEATH?
<br />30a. MAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />I
<br />YES O NO ❑ UNKNOWN
<br />❑ YES XNO
<br />O
<br />❑ YES XNO
<br />Edward P. Raines, M.D., 1919 So. h S 68
<br />32a. REGISTRAR �1 ` 132b. DATE FILED BN REGISTRAR (MO.. Day. Yr/
<br />LIAR 1 8 1992
<br />
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