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HomeMy WebLinkAbout20081082NUM PGS__ f DOC TAX CK#______,,,. FEES~_pp~_CK# ~ a7„y~ CHG ACCT #.____,.,,_, RET FEES~:1 ~ CASH u~~ R.O.D. CK#~_ RECD. JQirl~,~:_[I~[~hs RETURN ~ N~~~ s ar GBQo/ IVllllultdl~ll~!ulll!IIIAllllll~lllllll SlJM ~~ ~~D. COMP ~ ~~•~~( COP/1PARE CADAS - AO ~ ~-~ .~ , k~r WHEN TH/S COPY CARR/ES THE RA/SED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH, ;~~r. ? CERT/f/ES THE BFL OW TO BE A TRUE COPY OF AN OR/G/NAL RECORD ON fILE W/TH THE STATE DEPART/J1ENT OF HEALTH, BUREAU OF V/TAL STAT/ST/CS, WH/CH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS. NU~j i`.~`~j STAN EYS. COOPER "~~" ASS/STANT STATE REG/STRAR °"' L/l'JCOLN, NEBRASKA NEBRASKA DEPARTMENT OF HEALTH STATE OF NEBRASKA -DEPARTMENT OF HE~.L7H BUREAU OF VITAL STATISTICS CERTIFICATE GF DEATH ADAMSF OUDNTY, NE INST. NO.~ ~ $ 2 Date ~13:@~ Tim -~~~.~11 ~~~ REGISTER OF DEEDS The document filed is a co Signatures re n original. 3-I4-og Data itials ~oosios~ I. uee:¢utnl .NAM[ FIRST MIDDLE LAST 2 Sc'X J DATE G-" DEATH ;Monln Dar Y¢ai~ ~`~~` Carl La4rrence Harms t`9ale August 18, 1995 d CI7 JgND STATE OF BIRTH nlrwrn US.A. name coumryr 6a. AGE ~ La51 Blnnday UNDER 1 YEAR UNDER I DAV 6. DATE ~~ BIRiI+ :MOnm Oar Mean Rural Clay County, Nebra ska 'Y`S'82 Sb Mos ~ DAYS Sc HOURS MINS September 22, 1912 1 SOCIAL SECURTIY NUMBER Ba PLACE OF DEATH ' 507 12 5849 HOSPITAL ~ ____ --- ~-^ Inpalienl OTF{ER I I N~,S,ngHOm¢ LLJJ --- 80. FACILITY -Name 111 nor ~nsnNrrm, give str eet aria number/ ^ ER Oulpallent ^ 9es~cence I VA Medical Center 2201 N Broadwell ^ DoA ^ O , lne,r5~~,r1. Bc CITY TOWN OR LOCATION OF DEATH Btl INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island, Nebraska Yes ~ Nn ^1 Ha ll 9a RESIDENCESTATE 9D COUNTY _ '9c CI7 Y. TOWN OR LOCATIOn vp yTHCE; ArvD NUIriCt ~r w.iy [,p r.Wrr ~ Iti$IDE DiTY ;!I.n T.", , Nebraska Adams Hastings 310 E 9th St 68901 ' Y@~ ND ^ 10 RACE - le,g.. Wnne. Black. American Indian 11. ANCEST l I RY leg halloo. Me.ICan. German. elcl 12 ®MARRIED ^ WIDOWED 13 NAME OF SPOUSE I!r wAe prve ma~nen name ey,i log YI ISpec~lyl WW II 11 ll~, e ~ NEVER German ~MARRI DIVORCED Shirley Charlotte McLaughl 1 7Ja. USUAL vGCUPATIUN /Give klnd a' wort ppne dUnng nrDSl rNrAm li/e, en rl renre0l 1dD KIND OF 6USINE SS INDUSTRY ~ 15 EDUCATION IS:P-'.N only nigne5l gratle Cumpl¢ledl ruc~C giver Retired Self-employed EI ary or $¢cyCary 10~ 121 College I I ~d o~ S-~ q~`~ ~~~~~~~ ~.,.m~ renal mluu~[ LAJI I I7 MOTHER FIRST MIDDLE MAIDEN SURNAME (Dec) Fred Harms (Dec) Elizabeth Fredricks 18. WAS DECEASED EVER IN U.S ARMED FORCES? 19a INFORMANT -NAME ~ YesaunkJ IW~J¢I~¢w4~5tl~42~11/11/45 Shirley C Harms 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE ZIP( ~ 310E 9th Street, T~stings, NE 58901 .EMBALMER-S TURE EN 21a METHOD OF pISPOSITION 21 b. DATE 21C. CEMETERY OR CREMATORY NAME 951 ~ ^ Aug. 21, 1995 Edgar Cemeter Burial Removal FUNERAL HOME -NAME 27tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE McLaughlin Funer 1 Home ^Drematbn ^Oonalbn Edgar Cemetery Edgar, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP) 1;13 North Brown C'lav ('Antc~r ti~,l„--, r.t~-. cone 23. IMMEDIATE CAUSE - (ENTER ONLY ONE CAUSE PER LI FOR lat. Ibl. AND Icll I Interval between onset ono seam PART I ' a$mall Cell Carcinoma of Lung Willi Metastasis ,- 6 Mon,.hs UVE 7C. CR AS A CONSEQUENCE OF I ~ Interval between tinsel ono oeam IDI F DUE TO OR AS A CONSEQUENCE OF ' Interval between ousel aria oealn Icl ------ ~ - ---- --- -_.. , OTHER SIGNIFICANT CONDITIONS ~ CpndNOns conaibuling to Ine death but not relaletl PART III IF FEMALE. WAS THERf. A 2d gUTOPS'• ~ 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN .THE PAST 3 MONTHS EXAMINER OR CORONER II A 10 Sd I ges I Yes No Yes Yes No 26a Z6D. DATE OF INJURY /MO.. Day. Yr.J 26c HOUR OF INJURY 26tl. DESCRIBE HOW INJURY OCCURRED ACCMenI ~ Unoelerminetl M Su~cKle ~ Pentling 26e INJURY AT WORK 261 PLACE OF INJURY ~ Al dome, larm. sveel. Iaclory oh~ce builtlirg, etc /SpeciyJ 26g. LOCATION STREET OR q.F . M CITY OR TOWN STATE - ^ Hpnicltle Invesbgalron ^ ^ yes No 27a DATE OF DEATH /Mo. Day. Yr.J 28a DATE SIGNED /MO Day Ycl 28b TIME OF DEATH August 18, 1995 27D DATE SIG M n f ~~ NED yMo. Day. YrI A 28 27c TIME OF DEATH ~ ~ J ~ 2& PRONOUNCED DEAD /MO. Day, Yi 28a. PRONOUNCED DEAD /Noun € g ugust , 1995 5:10 AM o ~a z ~ ° _ ~ 27a T In f b &w M n e ast o my wnowletlae Beam ocrun ea al me time, Dale ono Dlace aM Due Io Ine CaVS¢I51 slalae ~ //~J /G /~ ISI nature and Tltk ~ / C ' ~~ ~I"" I 28e. On me Dasis. of examination an0a rev<:a~~:wn, i my opinion seam Occurced al me lime rime and dace an•.1 ifun lu Ine -a Sasl slale0. l ~, l L - / ~ / I$i nature arx7 Tltle ~ 29 DID TOBACCO USE CONTRIBUTE TO THE DEATHV 30.a AS ORGAN OR TISSUE D ONATION BEEN CONSIDERED 30.D WAS CC~.ScNT GRANTED VES ^ NO ^ UNKNOWN ~ VES ~ NO ^ YES © NO 31 NAME AND ADDRESS OF CERTIFIER IPHY $ICIAN. CORONER'S PHYSICIAN OR COUNTY ATIORNEYI hype p Pimrl Dormond E Metcalf, MD, VA Medical Center, 2201 N Broadwell, Grar:d Island, NE 68803 32a REGISTRAR ~{ 32D DATE FILED B~ -t ,IS TRAR /Ab. Day Yi/ ~____ ,~J. _ ~ A U G 3 01995 in