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1. DECEDENT - NAME FIRST MIDDLE LAST Sallymae NMI Hawkins 2 SEX Fema1P 3 DATE OF DEATH /Month. Day. Yea) ,T►inP 30 1998 4. CITY AND STATE OF BIRTH (If not 01 U S.A.. name country/ 5a. AGE - Last Birthday (Yrsl 4' 1 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (M Day. Year) V 4 i Lou. Cit Nebras • 5b. MOS. I DAYS 1 5c. HOURS MINS : 7. SOCIAL SECURTIY NUMBER 1 1 507 -54 -4867 8a. PLACE OF DEATH HOSPITAL Inpatient OTHER: ❑ Nursing Home 85 FACILITY - Name (If no) rnsafution, give street and number I 1 St. Francis Skilled Care Unit ❑ ER Outpatient ❑ DOA X Residence Other /Specino Skilled Care Ui 2 DATE SIGNED (Ma. Day. Yr) - 8c. CITY TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS Yes a No ❑ Be. COUNTY OF DEATH Hall County 9a. RESIDENCE - STATE 19b. COUNTY Nebraska Hall 5c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) #9 Navajo Dr_, 68803 9e. INSIDE CITY LIMITS Yes No ❑ 10. RACE - (e.g., White. Black. American Indian. etc.) (Specify) White 11. ANCESTRY le.g . Italian. Mexican, German. etc) 13 (Speufyt ` Polish/American 12. X MARRIED ❑ WIDOWE NEVER DIVORCED ❑ MARRIED ❑ 1 3. NAME OF SPOUSE ill wee. give maiden name) Francis Vern Hawkins 14a. USUAL OCCUPATION (Give kind of work done during most 9 1 rl 1 of workag life, even if retired) Homemaker 140 KIND OF BUSINESS INDUSTRY q i „ 1 l C1J Own Home 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 0-12) College ft .4 or 5-1 Elementary 8th 16. FATHER - NAME FIRST MIDDLE LAST i August NMI Stenka 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Katherine NMI Persak N o 1 N/A I Francis Vern Hawkins 190_INFORMANT MAILING ADDRESS (STREET OR R F D. NO_ CITY OR TOWN. STATE. ZIP) #9 Navajo Drive, Grand Island Nebraska 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO C_y- " 7 �., .. // - / ,- 210 METHOD OF DISPOSITION ❑ } { Bunal Removal 215 DATE Jul 3, 1998 21c. CEMETERY OR CREMATORY NAME Westliwn Memorial Park Gen _ 22a. FUNERAL HOM NAMFS Kleine Funeral Home ❑ Cfema'n ❑ Dona ° °° 21d. C OR CREMATORY LOCATION CITY OH TOWN STATE Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE. ZIP) 3213 W. North Front St Grand Island, Nebraska 68803 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE , PER LINE FOR la(. (0), AND (c)( Interval between o and decal lic ART ^ N�t `"'�\/� � AAA) 7 I Ij '. 'L�`1.4 JO Y a1 is) OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PART II PART III IF FEMALE, WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? I (Ages 10 -541 Yes n No [1 I AUTOPSY 2 CASE REFERRED TO MEDICAL EXAMINER OR CORONER n ��1 Yes 1-- 0_4E,___ Yes L I No lv'4 26a. ■ Accident Il Undetermined Ill Suicide [] Pending ■ Homicide Investigation 26b. DATE OF INJURY (Ma. Day. Yr) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e. INJURY AT WORK Yes No ❑ ❑ 267. PLACE OF INJURY - At home. farm. street factory office building. etc (Specify) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE VINO l NNIO1SAHd SO�DOaGe AG palaldelo3 3q Ol . DATE OF DEATH (Mo. Day Yr./ To be Completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY ONLY 28a. DATE SIGNED (MO.. Day W I 28b TIME OF DEATH 2 DATE SIGNED (Ma. Day. Yr) TIME OF DEATH C r 0 Cm) 28c. PRONOUNCED DEAD /MO Day, Yr) 28d. PRONOUNCED DEAD /Hour, my death occurred at P 28e. On the basis of examination and'or investigation. in m o 0 the time, date and place and due to the cause(s) stated. (Signature and Title) p �PT To the best of m knowle ea coned at the Ume ate Y dge con causels) stated. C ISIgnaWre and Idle) 1 d lac a due to the �� V ,\ 1(! ky DID TOBACCO USE CONT IBUTE TO THE DEATH? ,( ❑ YES NO _❑ UNKNOWN tea HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 1111 YES NO J 30( WAS CONSENT GRANTED/ ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) David R. Golan MD, 729 N. Cust , Grand Island, Nebraska 68803 32a. REGISTRAR 6 32b. DATE FILED BY REGISTRAR /Mo. Day Yr.) :JUL 21 1998 7 18 WAS DECEASED EVER IN U S ARMED FORCES? 4 7 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEII4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUL 2 21998 LINCOLN, NEBRASKA (Yes. no. or unk.) I Ilf yes. give w and dates of service:; (5) DUE TO. OR AS A CONSEQUENCE OF DUE TO, OR AS A CONSEQUENCE OF. 201397478 fi ANLEY S COOPER - ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL ; CS CERTIFICA DEATH 19a INFORMANT - NAME Interval between onset and death Interval between onset and death it t.