Laserfiche WebLink
1. DECEDENT - NAME FIRST MIDDLE LAST <br />`Ralph Frederick r <br />2. SEA <br />Male <br />UNDER 1 DAY <br />S DATE OF DEATH_ANeiip• Day. Vey <br />December 14,1996 <br />S. DATE OF BIRTH Da Y <br />(l CRY AND STATE QF IWTH Mnalh DEA. mawoar6M <br />Clay Center, Nebraska <br />y <br />SR. AGE • Use BliMlry <br />" "' 96 <br />UMOER T YEAR <br />MOS DRYS <br />Sc. HOURS setts <br />31 1900 <br />May , <br />T SOCIAL SEoull IY NUMBER <br />506.20.4114 <br />8• PLACE <br />OF DEATH <br />H08PITAL' I pM1aM OTHER <br />II Nursery Home <br />❑ ER 011 11 ❑ Rea10altoa <br />❑ DOA ❑ °mr Imo <br />8e FACILITY - Nana pYRaar4aAb+e prsasa11and, eNy <br />St. Francis Medical Center <br />CITY LMQTS (Sa. COUNTY OF DEATH <br />No ❑ f Hall f <br />ac CRY. TOWN DR LOCATION <br />Grams I <br />ad INSIDE <br />v.. <br />Ba RESIDENCE • STATE SD . COUNTY <br />Nebraska 1 Hall <br />9[. CITY. BONN ON LOCATION SE STREET AND NUMBER /iecAd v Z. Coo) <br />Grand Island ( 1719 N. Grand Island Avenne, 6880 <br />S. INSIDE CITY LMYTS <br />Yea ® Na ❑ <br />abt. Amn Indian. <br />10 RACE • N.B. White. & ma <br />�'P IIta ° <br />11. ANCESTRY N.g.. nasal Mp rc( wan. German. 1 I2. ❑ MARRIED r7 WIDOWED <br />Ame rican � U N EVER f OIVO...ED <br />13. NAME OF SPOUSE /a rata pea y <br />, name! <br />tat USUAL OCCUPATION IGne kind alrw dons Away mast � <br />araaagak awn aryaMO/ <br />Radio Die + atcher 3 <br />tap. KIND OF BUSINESS INDUSTRY q�� <br />`Y <br />Hall County Sheriff Department <br />IS r� <br />or Secondary p•t2 college n - ap5•+ <br />10. FATHER • NAME FIRST WOOLS LAST <br />Henry Spencer <br />17 MOTHER FIRST MOUE MAIDEN SURNAME <br />Anna Wendt <br />II WAS DECEASED EVER IN U.S ARMED FORCES? <br />(Yee no.0.WWI ' Or yea ova mar and Oros el arvlcaal <br />No I <br />I9a, INFORMANT - NAME <br />Carol Iieyinr <br />19N. INFORMANT MAILING ADDRESS STREET OR R F.D NO. CIF' OR TOWN. STATE apt <br />2411 South Blaine, G I d Island, Nebraska 68801 <br />20. E - HER- • r_ ,, U LICENSEE <br />_ i A i ,. /D <br />21 a. memo OF DEPOSITION <br />(] Buns! ❑ RamdYal <br />21b DATE <br />12/17/1996 <br />' 21c CEMETERY OR CREMATORY NAME <br />Westawa Memorial Park Cemetery <br />FUNERAL • • NAME <br />Apfel - Butler- Geddes Funeral Home <br />❑ Crsmeaa ❑ <br />210. CEMETERY OP CREMATORY LOCATION CITY ON TOMN STATE <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET ON RF.D. NO.. CITY OR TOWN. STATE DPI <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. tp. AND Ic(( My,* batmen onset and 011110 <br />PART 4./:fn,t.4?a2 Y ,�� 1 9as <br />DUE TO. OR AS A CONSEQUENCE OP Interval Demean onset one dean <br />(b/ CAR emioAt4 cbo 4t44/J, ! <br />DUE TO. OR AS A CONSEOUENCE OP Mga ael•rsan IS'1ar a0a Dear <br />Mel <br />Ignu contributing e death but not related <br />PART OTHER SIGNIFICANT CONDITIONS • COnM to m <br />It <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />r <br />(Ages 10.541 Yes I 1 NO n <br />24 AUTOPSY <br />Yea n NO <br />125. WAS CASE REFERRED TO MEU CAL <br />EXAMINER OR COIN NEWS <br />Yes Ti aaaalllI----,,,1111 <br />28a. <br />• Accident N Undettemined <br />N Sacade I♦ Pending <br />0 HMOS, raves gal on <br />28b. DATE OF INJURY iMO.. Day. WI <br />26c. HOUR OF INJURY <br />M <br />28d. DESCRIBE HOW INJURY OCCURRED <br />2911 INJURY AT WORK <br />Yes ❑ No ❑ <br />26f PLACE Daula 115 ale /Saaeay'l ' OF INJURY • �A�t 11gqrr77lIae farm. sheet factory <br />olce <br />26g. LOCATION STREET OR R F.D. NO CITY OR TOM% STATE <br />28a DATE SIGNED No Day Y,.t , 28D TIME OF DEATH <br />M <br />a <br />E <br />27a. DATE OF DEATH IMo. Day W.) <br />is 1-4— I to <br />E <br />27p. DATE SIGNED IMO. Day W/ r <br />' ��� I V <br />2711 TIME OF DEATH — <br />1 .] " -6(N - <br />2811 PRONOU DEAD IM O bey, y r + (led PRONOUNCED DEAD '*q,+ <br />S s M <br />270 To the DM my <br />my anp Medge ��TO acCNred a 811 dad and due to <br />caa e s NWT.* 1 , /' � "'� <br />(Wakes / r•T // , {jJ ,�wl I1 <br />U 28e On m e bawl d NammEbn ax i a ramie 9Ep' A mr apron map accu e <br />~ , , T` III NM. and add O lata a M dH M Mfr CMMasa flr id <br />' . 'SgnWAe and TA IA <br />25 DID TOBACCO USE CONT TO THE DEATH? <br />❑ YES 1X1 NO ❑ UNKNOWN <br />"�� " <br />30 a HAS ORGAN OR <br />TISSUE DONATION BEEN CONSIDERED? ( 30 D WAS CONSENT GRANTED' <br />II YES NO I ❑ YES vr. <br />a NAME Af10 ADDRESS OF CERTIFIER {PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY:. 1 7 r ,Ta a ? , M.•: <br />1 Dr. David R. Colan, 729 N Custer, grad bland, Yebilska 68803 <br />S:G 'Kt0 <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 " k 'CbPPS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS, A • <br />DATE OF ISSUANCE <br />SEP 3 0 2013 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />201308116 <br />• <br />STATE OF NESRASIIA — DEPARTMENT OF NEALTes ' <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />- `STANLEY OPER <br />ASSISTANTSSTATE REGISTRAR <br />DEPARTMENT OF <br />HUMAN SERV .5) • <br />4'974 <br />32$ DATE FILED BY REGISTRAR Mo Da. r, <br />DEC 27 1996 <br />