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1 DECEDENT - NAME FIRST MIDDLE LAST <br />Florence Dora Joy <br />2 SEX <br />Female <br />3. DATE OF DEATH tMomh Day. Year) <br />March 29, 1998 <br />4 CITY AND STATE OF BIRTH III not in U.S.A.. name country) <br />5a. AGE - Last Birthday <br />Yrs , 66 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH / Day Year) <br />March 8, 1932 <br />Ainsworth, Nebraska <br />Sb. MOS i DAYS <br />Sc . HOURS MINS <br />G 7 SOCIAL SECURTIY NUMBER <br />507 -48 -3928 <br />1 8b. <br />8a. PLACE <br />OF DEATH <br />HOSPITAL. Inpatient OTHER: Nursing Home <br />[] ER Outpatient ii Residence <br />DOA Other (Specdv, <br />FACILITY - Name Ill not institution. give street and number) <br />i 2612 O'Flannagan Street <br />W. 8.- CITY TOWN OR LOCATION OF DPATH <br />Grand Island <br />18d INSIDE CITY LIMITS <br />Yes !� No ❑ <br />Be COUNTY OF DEATH <br />I Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island' <br />T 9d. STREET AND NUMBER (Including Zip Codel <br />2612 O'Flannagan, 68803 <br />9e INSIDE CITY LIMITS <br />Yes gi No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />etc.) (Speedy) white <br />White <br />11. ANCESTRY le. g.. Italian. Mexican, German, etc) 12. �s� MARRIED ❑ WIDOWED <br />y7 NEVER DIVORCED <br />American MARRIED <br />13. NAME OF SPOUSE (d wile. give ma den name) <br />Alvin Joy <br />14a. USUAL OCCUPATION (Give kind of work done during moll - <br />1 of working life, even it refired) <br />' Seamstress <br />14b. KIND OF BUSINESS INDUSTRY <br />Drapery <br />15. EDUCATION (Specify only highest grade completed( <br />Elementary or Secondary 10.12) College t 1 -4 or 5- I <br />12th Grade <br />J 16. FATHER - NAME FIRST MIDDLE LAST <br />i William NMI Weber (Dec.) <br />t7. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Maud L. Burris (Dec. <br />- 18 WAS DECEASED <br />- (Yes no or unk.) <br />No <br />EVER IN U.S. ARMED FORCES? <br />III yes give war and dates of services) <br />N/A <br />19a. INFORMANT - NAME <br />1 Alvin Joy <br />19b INFORMANT MAILING ADDRESS (STREET OR R. F. 0 Na, CITY OR TOWN. STATE. ZIP) <br />2612 O'Flannagan Street, Grand Island, Nebraska 68803 - <br />20. EMBALMER - SIGNATURE 8 LICENSE NO. <br />WG 1 ) ,,., , ��., '_da .....1631 <br />21a METHOD OF DISPOSITION <br />mo <br />❑ Burial ❑ Reval <br />21b. DATE <br />Apr. 1, 1998 <br />21c. CEMETERY OR CREMATORY NAME <br />Central Nebraska Crem. Ser <br />22.. FU E HO E -N. <br />Kleine Funeral Home <br />►'.i Cremation ❑ Donation <br />210. CEMETERY OR CREMATORY LOCATION 0170 OR TOWN STATE <br />Gibbon, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR RE D. NO CITY OR TOWN. STATE. ZIP) <br />3212 W. North Front St., Grand Island, Nebraska 68803 . <br />IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lai O. ANND Interval between onset ono 00 <br />PART • <br />11 .. "/ /C mss! t!!// - � 1 ...�fiG / /r./ /C- yv .0lY7 <br />O NCE <br />DUE TO. OR AS A CONS OF / Interval een onset and dean <br />D <br />1 <br />DUE TO. OR AS A CONSEOUENCE OF• <br />Interval between onset and deam <br />) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />II _ <br />:: <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS/ <br />(Ages 10 -54) Yes - I No <br />24. AUTOPSY <br />Yes No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER/ <br />Yes n N Y 0 i <br />26a. <br />■ Accident Undetermined <br />■ Smcide ■ Pending <br />C Homicide Invesiigal�on <br />26b. DATE OF INJURY /Mo.. Day Yr./ <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OC URRED <br />home. farm. street factory <br />26e. INJURY AT WORK 1 261 PLAC ffice bwld ing, etc. INURJY - (Sp At ec ify/ <br />Yes ❑ ❑ oNo i <br />26g. '-, OCAT)ON STREET OR R.F D. NO. CITY OR TOWN STATE <br />- <br />27a. DATE OF DEATH /Mo.. Day Yr) <br />March 29, 1998 <br />28a. DATE SIGNED IMo. Day Yrl <br />28b TIME OF DEATH <br />AlNO <br />OISAHd §o puauti <br />p2laldwo0 eq el <br />27b. DATE SIGNED /Mo. Day. Yr) <br />March 30,1998 <br />27c TIME OF DEATH <br />12:10 AM M <br />e Completed <br />JER PHYSI <br />MTV ATTOR <br />ONLY <br />28c. PRONOUNCED DEAD IMO.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Hour <br />M <br />27d. To the best of my knowledge. death occurred at the I , date and ce and due to the <br />cause's) stated. - •' <br />Oil' (Signature and Title) 1 �1,. s <br />28e. On the basis of examination an4Jor investigation. In my opinion death occurred at <br />0 the time, date and place and due to the causelsl stated. <br />(Signature and Title) ► <br />29 DID TOBACCO USE CONTRIBU 0 THE DEATH? <br />YES = NO UNKNOWN <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />YES NO <br />30.b WAS CONSENT GRANTED/ <br />YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( !Type or Pont) <br />Jane A. McDonald MD, 800 N. Al ha Grand Tsland, NF 6880i <br />32a REGISTRAR <br />.,�.- <br />32b. DATE FILED BY REGIST�/ fMO..L7ay w( <br />ASP] ((VV"� uuJJ yy <br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />APR 8 1998 <br />LINCOLN, NEBRASKA <br />S. 2 013 0 9 93.3 ASSISTANT RR <br />HEALTH AND HUMAN SERVICESSYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS - - <br />CERTIFICATE OF DEATH <br />• <br />