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Rev. 11/97
<br />Signed in my pr
<br />STATE OF NEBRASKA- DEPAR7'MENT OF HEALTH AND HUMAN SERVICES FINANCE ANQ SIT( 5. 5 4
<br />VITAL STATISTICS 2 0 1
<br />FOR VITAL STATISTICS USE ONLY
<br />Place A B C D E Part II TMV
<br />NSC
<br />Census Tract No.
<br />Work
<br />UC
<br />Reject
<br />hereby certify this to be a true ana correc?(IZ*Ortli
<br />filed with the State of Nebraska
<br />(A
<br />CERTIFICATE OF DEATH
<br />day of 2.2.--,--a2.4-e
<br />Notary Public
<br />GENERAL NOTARY-State of Nebraska
<br />TERRY L. LOSCHEN
<br />My Comm. Exp.
<br />I DECEDENT - NAME FIRST MIDDLE LAST
<br />Richard Lewis Whitaker
<br />2. SEX
<br />Male
<br />3 DATE OF DEATH (Month. Day. Yee)
<br />November 7, 2001
<br />4. CITY AND STATE OF BIRTH lff not in USA.. name country)
<br />5a. AGE - Last Birthday
<br />(Yrs I
<br />67
<br />UNDER I YEAR
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH lAfonfh. Day. Year)
<br />May 24, 1934
<br />1-- Hastings, Nebraska
<br />5b. MOS. 1 DAYS
<br />1
<br />,
<br />5c. HOURS ' MINS
<br />Z 7. SOCIAL SECUFITIY NUMBER
<br />LL.I
<br />0 507-36-3423
<br />w
<br />84 . PLACE
<br />OF DEATH
<br />HOSPITAL: Inpatient OTHER. Nursing Home
<br />ER Outpatient 0 Residence
<br />DOA Other (Specify,
<br />(...) 81, . FACILITY - Name III not institution, give street and number)
<br />W
<br />0 106 N. 5th -
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Doniphan
<br />84 INSIDE CITY LIMITS
<br />Yes I No
<br />8e. COUNTY OF DEATH
<br />Hall
<br />9a RESIDENCE - STATE
<br />Nebraska
<br />91) . COUNTY
<br />Hall
<br />9c. CITY. TOWN OR LOCATION
<br />Doniphan
<br />94 STREET AND NUMBER (Including Zip Code)
<br />106 N. 5th 68832
<br />9e INSIDE CIT V LIMITS
<br />Yes N .., II
<br />10 RACE - (ag., White. Black. Amerman Indian.
<br />MO (Specify)
<br />White
<br />148 . USUAL OCCUPATION (Give kind of work done
<br />11 ANCESTRY (e.g.. Italian,
<br />(Specify)
<br />American
<br />during most
<br />Mexican. German, etc(
<br />141, . KIND OF BUSINESS INDUSTRY
<br />Steel Building
<br />12 n MARRIED WIDOWED
<br />NEVER MARRIED [] DIVORCED
<br />• L I
<br />15. EDUCATION
<br />11 NAME OF SPOUSE (ifIv Of MO idan 'wool
<br />Susan Hendrickson
<br />(Specify only tughest grade completed)
<br />of working fife. even if retired)
<br />Maintenance
<br />1
<br />Manufactur ing
<br />Elementary of Secondary 10-121 ' Colle 11-4 or Siiil
<br />' 1 Year
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />Lewis C. Whitaker
<br />17 MOTHER FiRST MIDDLE MAIDEN SURNAME
<br />Bernadine A. Vansant
<br />ii ie. WAS DECEASED
<br />(Yes. no. or unk,1
<br />No
<br />EVER IN U.S. ARMED FORCES? .
<br />I (If yes. g wa
<br />ive r and dates of servi(es)
<br />79a INFORMANT - NAME
<br />Susan Whitaker
<br />196 INFORMANT MAILING ADDRESS (STREET OR RF.D. NO., CITY OR TOWN. STATE, ZIP)
<br />106 N. 5th, Doniphan, Nebraska 68832
<br />29 EM E S1GNAT 6 LIC E NO 21a
<br />...
<br />METHOD OF DISPOSITION
<br />Ed Burial Removal
<br />21b. DATE
<br />Nov. 10, 2001
<br />21c, CEMETERY OR CREMATORY - NAME
<br />Cedarview Cemetery
<br />22a FUNERAL HOM ME
<br />Livingston -Sondermann F.H.
<br />Cremation Donation
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Doniphan, Nebraska
<br />221,. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803-4050 .
<br />23 IMMEDIATE CAUSE (ENTER 09417 0946 CAUSE PER LINE FOR lal Ib) AND (c))
<br />_,.„......."
<br />V) PART
<br />LIJ 'r xr'',.. o ef-/-1, .......
<br />la) . er ri‘ox ,,,e . .,. . .1 wle- e."0- .".
<br />- I7
<br />Interval between onset end death
<br />X ..-'-' e ../ .
<br />.......c:7,/
<br />7 DUE TO, OR AS A OF
<br />4 -...•
<br />0 IN /fed 7/Ye 4 . ..... r"...
<br />Interval between OfrAtt and dea
<br />DU TO. OR AS A CONSEOUENCE OF:
<br />Icl
<br />7 d Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death bul not related
<br />PART
<br />II
<br />PART III IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Ages 10-54) Yes No
<br />24 AUTOPSY
<br />X
<br />Yes No El
<br />25. WAS CASE REFERRED 70 MEDICAL
<br />EXAMINER OR CORONER?
<br />) y.in 940 71
<br />26a.
<br />• Accident . Undetermined
<br />111 Suicide 1111 Pending
<br />• Homicide Investigation
<br />261) . DATE OF INJURY (44o Day. Yr)
<br />28c. HOUR OF INJURY
<br />M
<br />264. DESCRIBE HOW INJURY OCCURRED
<br />26e. INJURY AT WORK
<br />Yes No
<br />261. latg INJe -A farm. street factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />cr
<br />W
<br />CC
<br />1.11
<br />o
<br />279 DATE OF DEATH (Mo.. Day. Yr.)
<br />November 7,2001
<br />28a. DATE SIGNED (Mo.. Day. W.)
<br />28b TIME OF DEATH
<br />7b. DATE SIGNED (Mo. Day. Yr.)
<br />November9,2001C
<br />2, TIME OF DEATH
<br />1:30pm m
<br />28c, PRONOUNCED DEAD (Mo.. Day, WI
<br />2M PRONOUNCED DEAD (Hour)
<br />17d. To the best of my knowledge. death occurred at the 6 date and place and due to the
<br />)(cause's) stated.
<br />4 - • e andlitle _ _ ..,itille „dr .., 4.,
<br />28e. On the basis of examinaton andor investigation, in my oMnion death occurred al
<br />0 the time, date and place and due to the cause(' stated.
<br />Si nature and Tale
<br />28 DID TOBACCO USE CONTRIB TO T E DEATH?
<br />YES IA: No UNKNOWN
<br />30.9 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />II YES NO
<br />30.b WAS CONSENT GRANTED?
<br />YES NO
<br />..cV
<br />1 NAME AND ADM acw_CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Ty* or Pnik)
<br />Dr Jane A McDonald MD 800 Alpha Grand Island,NE 68803
<br />328 . REGISTRAR
<br />328 . DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />Rev. 11/97
<br />Signed in my pr
<br />STATE OF NEBRASKA- DEPAR7'MENT OF HEALTH AND HUMAN SERVICES FINANCE ANQ SIT( 5. 5 4
<br />VITAL STATISTICS 2 0 1
<br />FOR VITAL STATISTICS USE ONLY
<br />Place A B C D E Part II TMV
<br />NSC
<br />Census Tract No.
<br />Work
<br />UC
<br />Reject
<br />hereby certify this to be a true ana correc?(IZ*Ortli
<br />filed with the State of Nebraska
<br />(A
<br />CERTIFICATE OF DEATH
<br />day of 2.2.--,--a2.4-e
<br />Notary Public
<br />GENERAL NOTARY-State of Nebraska
<br />TERRY L. LOSCHEN
<br />My Comm. Exp.
<br />
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