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<br /> �,r'i'�t�i���F��iE��Tlia4RID fiUArfAN SER1/10ES;SY.STEM,V[TALSTATJSTleS SECTlON,YYHICH/S
<br /> �3i��.�i�.�L�B��C?SIT€3ftYFOF't V/TAL 9�GOR!)S.`: . � �� , -
<br /> ��'":aa�"���t��F�s'��CE _
<br /> ANLEY S.COOPE32
<br /> �J 10/2 0 Q 3 ass�sr�wr sgaa r��casr��
<br /> �����=������� H�LrH��m Hv�t,an�se�zwces sYsr��r
<br /> STATE OF NEBRASKA-DEPARTMEN'T OF HEALTH;AND HUMAN SERVICES FINANCE AND SUPPORT
<br /> • VTTAI,STATTSTiCS
<br /> CERTIFICATE OF DEATH �� �����
<br /> EDEIVT�NAktE RRST _ MIDDLE LAST � � 2.SEX 3.DATE OF DER7H XMonth.Oay.Yea¢ � � .
<br /> �onnie g,ouise Hoffman Female June 2,2003
<br /> ;^7�ST.�a i E OP BIRTH 71 not in US.A..name countryJ . Sa.AGE-Last Birthday � UNDER 1 YEAA. UNDFA 1 OAY� 6.DATE OF BIRTH lMonth.Day..YearJ . '
<br /> �orYh�I�ite�Ne�3ras� Iv.s.t 49 Sb.MOS.i DAYS ScHOURS� M�Ns. . May 12,1954
<br /> .;LSECURTiYNUn�sBER � � ' 8a PCACEOFDEATH � . �
<br /> ,E�6-�IO-�r�'I3 HOSPRAL � lnpatient OTHER: � Nursing Home .
<br /> ;;LITY-Name (pr.orinstitution,gives(reelandnumber/ � � EROutpalient � Residence ,
<br /> 231��.Stailey Park Road � ooA ❑ Other/SPecdVr ,
<br /> :.'OWN OA LOChTION O�J:J+TH a � � � Sd.INSI�E C17N LIMITS 8e.COUNTY OF DEATH �7�u � � �
<br /> eYE.�i3�Y 1'.�fc�.ilYl ' � '
<br /> � Yes � No.� . .
<br /> �iLENCE-STATE 9b.COUNTY 9c.CITY.TOWNORLOCATION 9d.STREETANDNUMBER !lncludingZipCode) � 9e.INSIDECITYLiMITS �
<br /> 14Te��as�:� I�all Grand Island 2319 E.Stolley Park Road 68801
<br /> � . . ' . . Yes� No�� � .
<br /> CE-je.g.,White.81ack Ame^can Indizn. �7 t,ANCESTRY(e.g_Italiaa.Mezican,Gaiman,eic) � 12�MARRIED� � ❑�WIDOWED � 13.NAME OF SPOUSE (lfwiie:give maden nameJ�. �
<br /> ;,so��;;,,, �lnfte �sp�;y� American John Hoffman ,
<br /> , . NEVER� DIVORCED .
<br /> MAR 1
<br /> ��.OAI�JCCUPATION !Give kiPd oi work done dunng mast� � �t4b.KIND OF BUSINESS INDU57RY � � -75.EDUCATION (Specify onty highes[grade completed) • � �
<br /> �;rorkir.g life,even if retired) �) �QblSfei�CC1 NllTSC P11bI1C SCIlOOI�S3TStBI11 _ �emeniary or Secondary(0-�2) : College�It=a or 5�1 � '
<br /> 12 4
<br /> Tti�R.tWME FlFS7 .M16DLE • LAST 17.�MOTHER FIRST � MIDDLE MAIDEN SURNAME � �
<br /> .i ack Mogensen Gertrude Egaers
<br /> +�S DECEaSED EVEF IN U.S.ARhiED FORCES? � . 79a.INFORMANT-NAME� - JOuIl HOl�
<br /> nk.� (if yes.give�.var and daes of sarvicesJ �� .
<br /> -�'-'�'-`�' . . , . . .
<br /> 2fOR41ANT � MniLWG ADDRESS �STR ET OR R.F:D.NO_CI7Y OR TOWN.STATE ZIPj- _ .- � .
<br /> 2319�.S�tolley Park Road,Grand Island,Nebraska 68801 � . ,
<br /> -5�E.ME SIGNATUR�3Li �hSE'�. � � 21a�MEfHODOFDISPOSITtON 21h DATE � 27c.CEMETERYORCREMATORY�NAME
<br /> 1 ;': 7 .-�:' r a , ' #1071 June 5,2003 Broken Bow Cemetery
<br /> ', / �,.i,{ % ' �,� �:�.��F,� . �..Bunal �Removai � � � �
<br /> ��,'�ticH.1:riOt�ic-PW,ME � " - Ztd.CEMETEftY OR CFEMATQRY LOCATION CITY OR TOWN .STATE -
<br /> �il�ait[�s�'��a�rai Home � � Broken Bow,.Nebraska
<br /> �Cremauon Donanon �
<br /> .,'��AL HOt.1E ADLRESS ISTREET OR RF.O.NO..CITY ORT�WN.STATE,ZIPj - � � . �
<br /> 2929 S.Locust S#.,Grand Island;Nebraska 68801
<br /> .',tai`�:�r��HUS - � .� , (ENTER 6NLY ONE�AUSE PER IJNE FOR 1a7.(b�,AND,cj� . � . i �ntenral beN✓een onset dnd.dea[h
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<br /> t:�E'C�.V�?.5 A GO�S'v'�J�NCc�`. �. �- �. . ._ � � - lircervai benveert onser and tleam -
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<br /> 'i � ��ii�t �X/T�� . . ' . � ' � �
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<br /> '�l'E:6.UR AS A CONS�UE,CE OF: � 1 Interval ween onset and tlealh
<br /> ��' 1
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<br /> QTxca S:6NlFtCAu?C��sillTtOUS-Ca�lions contri6uling s ihe deaih but not reiated PART lll 1F FEMALE.WAS THERE A 24.AUTOPSY 25:WAS CASE REFERRE��TO MEDICAL � .
<br /> �.,i i � � PREGNANCY IN THE PAST 3 MONTHS? . IXAMINER OR CORONER?
<br /> it
<br /> . � • (A9es 10-541 Yes No x Yes No Yes No
<br /> �26b.DATE OF INdllRY ]Mo..Day.Yr�J 26a HOUR OF INJURY 26d DESCRIBE HOW INoJRY OCCURRED
<br /> �ccde�i � Untletermired � M . . . � � . .
<br /> ticc�e � Peadi�g �26e.INJURY AT WORK 26f.PtAGE OF INJURY-At hoJne,fatm.SVeet.FdCtory � 26g.LOGATION � , STREET OR R.FD.NO. �_ CITY OR TOWN � STATE �
<br /> ❑ ❑ of�ce buiiding stc. (Spec+ryl �
<br /> �.n-�.c�de �nvesegancn Yes No � � � �� �
<br /> �Z,a.uAic OF DE..Tri (mio:.7av.YtJ , � � 28a OATE SI6NED (Mo..Oay.Yr.J . 28b.TIME OF DEATH � � - �
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<br /> %7d c nt 9 si at-ry���w�c4�¢�Yh�e�ur .ac 2n��r��te 3n�!p1����ne aue[o the Zee�.bn me oasis ot gxammauon ana or mvestiganon In my opinion deaih occurred ai� .
<br /> a.vs_Is1+ai�s.+. : ( � u�� riiee iGne date_antl place and dua�to die cause(s�svsced�.
<br /> �.ti -.i .anc 7��� Y"�.� _ ��. � � . . . �IS"nature-andTitlel6 . . .
<br /> ".:i�3P.,.Lw USE ANTRI�U��v THG SATFi? . t $0,�3'�$QR{'�hLQR TIy4$L)E DC�N/il'7�N BEEIV COIJSIDE�i��J? ' $O:b��P%A$C�iV3€NT GFI.6NTE63 ' „ • �
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<br /> � YCS �NO � UNKNS3VtN� . � YES �� � . ,� Y� . � ' .
<br /> F� . . . . .____ .� _. . • 9 .
<br /> �;:r.rc.+,vb.�n�Rc'SS OF�EFTIGIE4;PHYSICIAN,COAONB�'6 PNYSICIAN OA COUNTY ATTORNEY) (Type arPrinp � � ' " � . � �
<br /> �iiki�apux M:D.,2116 W.Faidley Ave�Grand Island,Nebraska b$$03
<br /> - -i �� � �� ,�- . � � � � 32b.DATE F1lEQ BY RE�ISTRAR (Mo..Day.Yc1 .�
<br /> .."._, n . � . .
<br /> JUN �9 Q
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