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. DECEDENT - NAME FIRST MIDDLE LAST • Virginia Gl adys Jahn 2. SEX Female 3 -SATE OF DEATH (Month. Day. Yee,) September 23, 2004 CITY AND STATE OF BIRTH pl not m USA. name country) Holdrege, Nebraska 5a AGE - Last Birthday (Yrs.) 91 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) June 30, 1913 5b. MOS. I DAYS 1 5c. HOURS' MINS. •. SOCIAL SECURTIY NUMBER 357-12-0079 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER: ❑ Nursing Home b. FACILITY - Name (I( Motion, owe street and number) Q lanni an 2620 on Street w ❑ ER Outpatient 9! ❑ DOA ❑ Residence Other (Specrfv, '.c. CITY. TOWN OR LOCATION OF DEATH • Grand Island 8d. INSIDE CITY LIMITS Yes x No ❑ 8e. COUNTY OF DEATH Hall e. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION. Grand Island 9d. ST §T NUMBER (I ncluding n Cade) 2620 Orl 68803 9e. INSIDE CITY LIMITS Yes r No ❑ 0. RACE - ( Whne. Black. Amencan Indian. etc.) (Specify) White 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) (Specify) American 12. r MARRIED ❑ WIDOWED NEVER DIVORCED ❑ MARRIED ❑ 13. NAME OF SPOUSE Ill wife. give maiden name) Phil Jahn 4a. USUAL OCCUPATION (Give kind Of work done during most of working life, even if refired) Homemaker _ _ 14b. KIND OF BUSINESS INDUSTRY Domestic 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -12) College 11 -4 or 5 -1 12 _ • 6. FATHER - NAME FIRST MIDDLE LAST Edward Larson 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Lydia Gustafson 8. WAS DECEASED (Yes, no, or unk.) NO EVER IN U.S. ARMED FORCES? le yes. give war and dates of services) 19a. INFORMANT - NAME Phil Jahn 20. EM0fiCK fR -- SIGNATURE 8 LICENSE NO. L Y� 22a. FUNERAL HOME Apfel - Butler- Geddes Funeral Home 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 W. 2nd St. Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). Ib). AND (c)) PART / } gti 8 8 J r 2 e t SS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 2620 O'Flannigan Grand Island, Nebraska 68803 (b) 32a. REGISTRAR WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL !RLCOR_D_,ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICCIMECTI011 , WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 201501_099 ANLEY S. COOPER ASSISTANT-STA:TREGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSIEIMT STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAICE AND SUPPORT VITAL STATISTICS - - 10/13/2004 21a METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation ❑ Donation 21b. DATE Sep 25, 2004 Holdrege DUE TO, OR AS A CONSEQUENCE OF- DUE TO, OR AS A CONSEQUENCE OP: (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 26a. O Accident 0 Undetermined O Suicide 0 Pending O Homicide Investigation 26e. INJURY AT WORK I_261 . dlfioe building eUtRY Zug, farm. street. factory Yes ❑ No ❑ alfi 27a DATE OF DEATH (Mo.. Day. Yr.) 27b. DATE SIGNED (Mo.. Day. Yr.) Sept. 27, 2004 U 26b. DATE OF INJURY (Mo.. Day. Yi4 September 23, 2004 26c. HOUR OF INJURY 27c. TIME OF DEATH 4:00 a 27d. To the best of my knowledge. death occurred at me, date and place a - due to the causelsl stated. (Signature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEAT`P 30.a H ORGAN OR TISSUE DONATION SEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES RNO ❑ UNKNOW ❑ YESNO ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gordon J. Hrnicek M.D. 729 North Custer CERTIFICATE OF DEATH 21d. CEMETERY OR CREMATORY LOCATION 28a. DATE SIGNED (Mo,. Day. Yr 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) Grand Island, Nebraska. 68803 21c. CEMETERY OR CREMATORY NAME Prairie Home Cemetery , Nebraska PART III IF FEMALE. WAS THERE A 24 AUTOPSY PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 -54) Yes I I No • Yes 264. DESCRIBE HOW INJURY • CURRED CITY OP TOWN STATE 269. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE 28b. TIME OF DEATH 28d. PRONOUNCED DEAD (Hour) 28e. On the basis of examination anchor investigation. in my opinion death occurred at iii p the time, date and place and due to the causels stated. (Si. nature and Title ► 32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.) �4 1071 Interval between onset and death Interval between onset and death Interval between onset and death 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER ? I Yes I No ki OCT 4 2004 M