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I Ic7 <br />326 REGISTRAR <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE / '�""^lf 4 '1 <br />OCT 0 6 2008 <br />LINCOLN, NEBRASKA <br />1 DECEDENT -NAME FIRST MIDDLE • LAST <br />Linda <br />Louise <br />2 SEX , <br />Female <br />Sc. HOURS - PAINS <br />3 <br />LINDER 1 DAY <br />( a. CITV.AND STATE OF BIRTH Inotn USA. nom MUvAp <br />Cloquet, Minnesota <br />° 7 SOCIAL SECL'RTIY NUMBER <br />477 -58 -0042 <br />; Bb F AMITY -Horne _. — _. Med HM/u/i865 gam:t a/a46Il7 7 <br />St. Francis Medical Center <br />= 8e CITY TORN OR LOCATION OF DEATH <br />Grand Island <br />9a RESIDENCE - STATE 90 COUNTY <br />Nebraska Hall <br />10 RACE - (e.g. WMe. Black. Amencal llalan . <br />alp l tsdelt e <br />16a USUAL OCCUPATION /Gnmaoddwale donedwFg may <br />deonaaglac, an/Taer.dr <br />Elementary School Teacher <br />20 EMBALMER - SIGNATURE 6 LICENSE NO <br />Not Embalmed <br />Apfel - Butler- Geddes <br />DUE TO OR AS A CONSEQUENCE OF <br />Anne K. Morse M.D. <br />STATE OF NEBRASKA <br />2 01300017 <br />STANLEY SUCOOPER. <br />ASSISTANT STATE REGISTRAR <br />DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATIS11CS <br />CERTIFICATE OF DEATH <br />16. FATHER NAME FIRST MIDDLE LAST <br />Ray Ketchum <br />11. ANCESTRY leg Galati. Me9can. Gentian. et <br />1S0eeN' American <br />• <br />DUE TO. OR AS AC SE <br />"AAA 4844 WAG 6040UOUNAs <br />OTHER SIGNIFICANT COND)TIUNS • Codd bons cabl Ming to (Ile death 638 me relalec <br />Merchen <br />5e. AGE - Lab 8381d1y UNDER 1 YEAR <br />(Yrs. 54 S6 MOS DAYS <br />146 KIND OF BUSINESS NDI.rTRY <br />Education <br />El <br />:N <br />226 F'ERAL HOME ADDRESS (STREET OR R.F.D. N0 CITY OR TOWN STATE ZIP) <br />8a PLACE OF DEATH <br />1123 West Second, Grand Island, NE 68801 <br />IMMEDIATE 173 IMMEDIATE CAUSE ■ENTER ONLY ONE CAUSE PER UNe FOR a *6i. AND :on <br />PART n � <br />-1 I - Y <br />Ia; <br />03 05241 <br />DATE OF DEATH Mama .7y yaw <br />Ap ril 29, 2003 <br />6. DATE OF BIRTH Wan" .y Year( <br />August 25 1948 <br />HOSPITAL ® avow -OTHER ❑ . Nuranq Houle <br />❑ ER 0s 1846 ❑ Readence <br />❑ DOA 0 D o . . Spear. <br />80 NSIDE CITY man I u.. COUNTY OF DEATH • <br />I • Yes a ❑ I <br />9c CITY TOWN OR LOCATION <br />Grand Island <br />1 12 IN MARRIED <br />❑ NEVER <br />MARRIED <br />17 MOTHER FIRS 7 LKODLE 11AIDEN SURNAME <br />Grace <br />Hall <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? { 1938 NFORMANT -NAME <br />(Yes O B I di yes. give war and dates 01,enneesl <br />I Kenneth R. Merchen <br />196 INFORMANT MAWLNO ADDRESS (STREET OR R.F D NO CITY OR TOWN STATE ZIP) <br />IP.O. Box 13, South Bend, Nebraska 68058 <br />2ta METHOD OF D15P051105 I 21 DATE .. 21c CEMETERY OR CREMATORY NA/AE <br />❑ anw ❑ Rnrtk.Ya April 30, 2003 1Central Nebraska Cremation <br />223 FUNERAL HO//E - NAME 21d CEMETERY OR CREMATORS LOCATION <br />Cre.aaa, ❑Dave,,, Gibbon, Nebraska <br />11 5 6 1 5 8 FEMALE WAS THERE A ' 23 AUTOPS I x ".YAK L.a5E kEFEARIEO TO MEDICAL <br />PART <br />„ PREoN:.tdov Pe THE PA ST 3M�NITNS' I EAAMINEROR COR04ER <br />i Rs 10 Yep ❑ No <br />Ye, [ No S i Ye, i No g <br />1238+ f 256 DATE OF INJURY /MO Day V,J i 26c 6401(R OF NJURY — <br />�'. ?Fd DESCRIBE HOW IN,i4_R'Y .rl l� -4RED <br />1 O AccoeM D Undetrnme6 <br />F� 1.--- M <br />I 1 ] Se,ctee 0 Pene:ne 78. NJIi9Y AT WORK 1 262 PACE OF INJURY - AI none Oar -. ,!....:, +acpry <br />1 ❑ o0 WON] ea: 'Wavy) <br />I HOm,clde Investiatvin ❑ Yee Fb <br />3 27a DATE OF DEATH ,leer ON WJ <br />27f DATE <br />r�]1 A D T SIGNED ,Ma 0... 2 - ' 27c T*AE OF DEATH �j y <br />/LL L(. 1 ,. la Z4J3 )2 nJ'�/ O M <br />1 210 To me Deaf oOns IN:a:edge Oealhof Wred at Me Mae date ar:G°We and Sue io me ? Y <br />Ca05M5 Sealed -- ' -[ - 2866 7 ✓ 6 41. 3 0 o . ... . ^ sere ar vw, ,. s e s e . . „ pr.or- Dew". ?s V•ad ar <br />` '] 'It. 1. --- + r.r�e owe ano orce...o - n,e><�+r cs:,se+s• awl►- <br />SNnawre and Tar. 11 (P11444. { ► &za1 °e an° T+°e # <br />29 DI0 TOBACCO USE CONTRIBUTE TO THE MEATH ,. 30a HAS ORGAN OA 31SSl.( .noNATIDN WEN :'ONSIT3ERE,Iv <br />❑ vES p(I NO ❑ UNKNOWN i Q YES <br />31 NAME AND ADDRESS OF CER70F*E1 , PHYSICIAN CORONER 5 PHyMCiAN OP COLM{TY 677710Nc T - on a <br />2 eeXAIWA <br />78a DATESIGNE0 Ali Om <br />99 STREET AND NUMBER ' ;arxdrgZZ Cane 9e INS/OE CITY LIMITS <br />408 Eisenhower Dr. 6880 Yea ®No D <br />❑ WIDOWED 13 NAME OF SPOUSE IN wife gra Namara name <br />n DIVORCED Kenneth R. Merchen <br />1 75 EDUCATION (SPecdy on* ng6162 grade canpkNU1 <br />Ele y2 Secondary ') 12) Cadge r l - or 5 <br />STREE . C NO <br />729 N. Custer, rand Island, NE. 68803 <br />Southerton <br />CITE 'iP TOWN STATE <br />286 TARE OF DEAN- <br />µ' 01 .Y Y' 760 PR(.'aMOIMK_E ✓DEAD -a ,. <br />34 r. .AS CONSENT GNAWED <br />D os Ua! <br />371 . 7A Fry7D 9 56 ,=Y,'RAG .r :.irr •. <br />tepee160eean 661666 a0G Yx <br />I ( 1 9 50 <br />are ar+c n-,r <br />382 -Ar..7 <br />!)merman bleat ene �:ae <br />738 TOW% 574 1 <br />M <br />MAY 9 203 <br />