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1 : DECEDENT. NAME FIRST MIDDLE LAST <br />Opal Irene Marsh <br />2 SEX <br />3 DATE OF DEATH /Morn Dar Vow <br />April 30, 2003 <br />a CITY AND STATE OF EARTH AreaaT US MmI .0ul16, • <br />S, AGE - Lap SON* <br />UNDER t YEAR <br />_ Female <br />UNDER / DAY <br />6. DATE OF BIRTH Mole Dee veal <br />May 21, 1915 <br />Sr ;khan, Nebraska <br />(YIN I <br />87 <br />51) NOS 1 DAYS <br />Sc. HOURS PAWS <br />z 7 ' ,"`GA SECURER' NUMBER <br />506 -72 -9503 <br />ea PLACE OF DEATH <br />TA ro.rla OTHER <br />HOSPITAL 0 I <br />C ER 061911964 <br />❑ DOA <br />r N..... <br />0 6b FACILITY - Name INro+ HAMAron. 9'•e sase/ar14 MARE(() <br />r <br />o Tiffany Square Care Center <br />MI <br />RpvOMCe <br />Owar <br />e0 CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />ed <br />NSIDE CITY UNITS <br />" © No II <br />ee COUNTY OF DEATH <br />Hall <br />Be RESIDENCE - STATE {94 COUNTY <br />Nebraska 1 Hall <br />Sc CITY. TOWN OR LOCATION <br />Grand Island <br />eat STREET AND NUMBER !hc/u°Y424 Code! °' IOECITY LMRS <br />1705 S. Blaine, 68803 i Ye M Mb ❑ <br />10 RACE - le WIles. Woos Amman YW+an 1 11 ANCESTRY le.g. bpMI.MN¢an. <br />Re i!ISOeeayl IS9eeth4 <br />White English <br />144 USUAL OCCUPATION awe W elol wore dory dewgwest 1 tab <br />or 1/9444141 Ivan Pelted) <br />Homemaker I <br />Garman. alc1 <br />KIND OF BUSINESS INDUSTRY <br />12 � MARRIED <br />LJ <br />• H <br />. WIDOWED <br />ii DIVORCED <br />1tE EDUCATION <br />MF <br />f 13 NAME OF SPOUSE re me 9.eraaaMA NM* <br />R. Wayne Marsh <br />(Sway only NOMApada 601601ar61 <br />Mammary or Seeoncary 4.121 COaup - a Of S-+ <br />Domestic 12 <br />J3tiV <br />16. FATHER - NAME FIST MIDDLE <br />Wilbur Wilcock <br />LAST 1 <br />I T MOTHER FIRST MIDDLE ,e dDEN SURNAME <br />Bird <br />1 1705 <br />1e WAS DECEASED <br />(Yes ' 01 lAal.1 <br />no <br />EVER IN US ARMED FORCES" <br />Id yes glue wan alq Oates M segnIcaa) <br />_Nellie <br />lEo INFORMANT - NAME <br />1 R. Wayne Marsh <br />190 INFOF'MANT MAIUNG ADDRESS (STREET ORR F 0 NO. CRY OR TOWN <br />SQ a :1, _ ;, _ ., <br />TATS. BPI <br />\ - • aska 68803 <br />20 EMBALMER - SIGNATURE & LICENSE NO <br />• .4 • LJCAUL AAN4 fel l412. <br />21a METHOD OF DISPOSITION <br />F Whorl [❑Remora• <br />21b DATE 1 210 CEMETERY OR CREMATORY NAME <br />1 May 3, 2003 ! Cedarview Cemetery <br />FUNERAL HOME - NAME <br />Apf el-But ler-Geddes <br />E] `rmattA ❑DOnatR <br />1 214 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />1 Doniphan, Nebraska <br />229 FUNERAL HOME ADDRESS ISTRLET OR R.F.O NO CITY OR TOWN STATE. YIP( <br />1123 West Second Street, Grand Island, Nebraska 68801 <br />23 IMMEDIATE CAUSE ({,. r ,a+ ( TENTER ONLY ONE CAUSE PER LINE FOR u 111 AND 101: wawa. belwearl Oyer awe Ara ++ <br />P AR rai y 1 1 44_.\ 41'- jj <br />t � 1 �' \ WL <br />DUE ET TO. OR AS A CONSEOUEt.'CE OFy.� elleeIa. beNwan Tura and dear. <br />Ill ^ -.J<-'VZ. V}� V 01 VI ��+�� �r <br />DUE !co OR AS A CONSEQUENCE OF Irge..a oe+we« +a•wer r+e cem <br />, t� \ veri -11. i . 1•.)N, `O T_. <br />OTHER SIGNIFICANT CON NS ConrMons cambu a Me neng Death AR Wale, <br />PACT OTHER <br />11 r '� <br />PART III IF FEMALE WAS THERE A <br />PREGNANCY IN THE PAS' 3 MONTHS' <br />Ages 1 0.54I Yes No <br />24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />Tir' <br />1 Yes n NO Yes No . 1 <br />07 <br />iFi <br />DATE OF ISSUANCE <br />JUL 112013 <br />LINCOLN, NEBRASKA <br />41cgen _ n ! <br />E GISTR b ."" 12. " C�e1� — r <br />1 REGISTRAR <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT Alfi <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE 0;wlS <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICE47 V 1TAI. RfCO.QD <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />S +ATTLEY aCi <br />•A4SIS7eAN' ' <br />DEPOriNENT dF <br />H <br />siATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE 'SU1PORT <br />201306 <br />vme SWIMS :03, -05240 <br />CERTIFICATE OF DEATH <br />268 DATE OF INJURY !AM Day ✓r (; 1.6c HOUR OF ?RUIN ' 2E4 DESCRIBE HOW INJURY OCCURRED <br />M <br />5wc - de V P en°mg 26e INJURY AT WORK 261 11,ACE OF INJURY • At Iwm5 la1-1 1 +•401 40 0, ; 26 LOCA N STREET 0. R F D NO <br />HpmK+de IavesngaN.+ � Yes No 1 <br />21e DA TE OF DEATH .Afo Doe w/ 280 DATE SIGNED /M, Ual 1' <br />• OR 'OWN <br />2It. TIME OF DEATH <br />April 30, 2003 = M <br />I, 1 ,. , ; 27b DATE SIGNED !MO Day w+ 270 TIME OF DEATH g 1 280 PRONOUNCED DEAD .M,+ Day w ( 264 PRONOUNCED DEAD AN, 385 f t- 6 N + N <br />a May 2003 2:05 <br />e 3•6 'I+ I e Deal of y YAPwkege death Oeturc,4 et Iy wee WTI! aa, Mace and eye IA the <br />g `'3. ?ee tl^ me •eLa d erim+nay0' a'b 01 »IVyrgaho+l vn my weer 0*0d+ Occvra4.Tr <br />cause s. <ta s)-5,. +ne •.me Bale a [Nate a ^d 0140 dM cwallel SbH4 <br />G maure 0110 T Id , & . 1 . 1 - - 1 11.7.3" 2......1 <br />5 , g nature and i:r <br />29 :1+r 'LI, ^O USE CONTRIB E TO THE DEATH+ 20a HAS ORGAN OR *IS3 .11 Or ( SEEN COrISIDEREO' 30S WAS CONSENT GRANTED' �} <br />0 <br />YES ❑ UNANOWN i C r Ec [ ' T,, I I 'E I .YYe1S <br />LLL 111 i LJ LJ <br />NAME AND ADDRESS OF CERTIFIER ■PHI'SICIAN. CORONERS PHYSICIAN OR COUNTY AT TONNE, %Pe d' •.,", <br />Sr nL Island, Nebraska 68803 <br />32o : 'E F■LEC 6r AEGIS/AA. <br />MAY 9 2003 <br />STA it <br />