Laserfiche WebLink
1. DECEDENT - NAME FIRST MIDDLE LAST <br />Charles Thomas Coppersmith <br />2. SEX <br />Male <br />3. DATE OF DEATH /Month. Day. Year) <br />January 1, 2002 <br />4 CITY AND STATE OF BIRTH 111001 in USA.. name country) <br />Grainton, Nebraska <br />5a. AGE - Last B'Irthday <br />(Yrs.l <br />8 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day Year) <br />October 20, 1921 <br />5b. MOS. I DAYS <br />5c. HOURS' MINS <br />7 SOCIAL SECURTIY NUMBER <br />519 -40 -6987 <br />80. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER <br />II Nursing Home <br />❑ ER Outpatient 4 <br />❑ DOA ❑ <br />Residence <br />Other (Specify) <br />B b. FACILITY - Name Ill not institution, give street and number) _. <br />420 E . 7th St. <br />24 AUTOPSY <br />+-. _ r � <br />Yes Ns ' <br />8c CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d. INSIDE CITY LIMITS <br />Yes <br />Be 1. COUNTY OF DEATH <br />Hall <br />RESIDENCE - STATE <br />ebraska <br />9b COUNTY <br />Hall <br />Sc . CITY. TOWN OR LOCATION <br />Grand Island <br />90. STREET AND NUMBER (Including Zip Code) <br />420 E. 7th St. 68801 <br />9e INSIDE CITY LIMITS <br />Yes a No ❑ <br />10 PACE - le.g., White. Black. American Indian <br />etc I (Specify) <br />White <br />11. ANCESTRY leg Italian. Mexican. German, etc/ <br />(Speclfy) <br />American <br />2 itil MARRIED ❑ WIDOWED <br />NEVER DIVORCED <br />MARRIED <br />` 13 NAME OF SPOUSE (It wile give maiden name/ <br />Pauline Wiebe <br />/AL OCCUPATION /G■ve trend of work done during most <br />of working hie. even if refired) <br />Farmer I <br />We KIND OF BUSINESS INDUSTRY <br />Agriculture <br />15. EDUCATION [Specify only highest glade completed) <br />Elementary or Secondary I0 -121 College ,1 or 5 <br />Unknown <br />Yes <br />1WWII 6/30/1942 - 11/30/1941 Pauline Coppersmith <br />19b INFORMANT MAILING ADDRESS (STREET OR RED NO CITY OR TOWN. STATE. ZIP) <br />420 E. 7th St., Grand Island Nebraska 68801 <br />20 BALMER - SIGNATURE 8 LICENSE NO <br />fl _(�, �.Xi r�2/� 1.�,�j � f g/) / 7 d 3 <br />/ - QfC- ,i7� <br />21a. METHOD OF DISPOSITION <br />A �r Burial Removal <br />❑ <br />❑ Cremation ❑Donal'°'' <br />21b. DATE <br />Jan. 5, 2002 <br />21c CEMETERY OR CREMATORY NAME <br />Westlawn Memorial Park <br />22a FUNERAL HOME , NAME <br />Livingston - Sondermann F.H. <br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />_ 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tat ibl. AND Icll I Interval between onset and death <br />PART <br />� 1 ' , Natural causes' � I unknown <br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and (learn <br />7 <br />h )b) <br />°e DUE TO, OR AS A CONSEQUENCE OF <br />IC) <br />Interval between onset and death <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />II <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10 (54) Yes r No ❑ <br />24 AUTOPSY <br />+-. _ r � <br />Yes Ns ' <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Yes No <br />26a. <br />. Accident II Undetermined <br />■ Swede . Pending <br />III Homicide Investigation <br />26b. DATE OF INJURY (Mo.. Day. Vc) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes No <br />❑ ❑ <br />261. PLACE OF INJURY - At home, farm. street. factory <br />office building, etc (Specify) <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />270. DATE OF DEATH (Mo.. Day. Yr) <br />28a. DATE SIGNED (Mo.. Day Yr l <br />- 7 0 c ) <br />28b. TIME OF DEATH <br />9:30 amM <br />275. DATE SIGNED (Mo.. Day Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo. Day. Ye) <br />January I, 2002 <br />28d. PRONOUNCED DEAD (Hour) <br />10 :36 amM <br />27d. To the best of my knowledge. death occurred at the time date and place and due to the <br />' cause(s) stated. <br />(Signature and Title) O. <br />On the basis of examination . - ; or move• I•. • • . opinion death occurred at <br />t tpe date and place an /ue to the ause(s) Sri - r. <br />288e. <br />(Signature and Title) ► <br />• 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ YES ❑ NO UNKNOWN <br />30.0 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />"1--- ❑ YES NO <br />30.b 5 - - ONSEN G - N EDT <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) <br />S:t D Osterman GIPD 131 S Locust Grand Isl.nd '5E .. <br />32a. REGISTRAR <br />aril( (1.174//0A <br />32b. DATE FILED BY REGISTRAR (MO. Day. Yr) <br />JA3 9 200? <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAt&SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE7D ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS' CTION., _WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />JAN 10 2002 <br />2 015 0 3 3/ 6 N y dNL£Y COOPER <br />ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO T <br />VITAL STATISTICS _ 0 <br />CERTIFICATE OF DEATH <br />i 16 FATHER - NAME <br />William Harlin <br />FIRST <br />- 1 8 . WAS DECEASED EVER I N U S . ARMED FORCES? <br />(Yes no or unk.l III yes. give war and dates of services) <br />!', <br />MIDDLE <br />LAST <br />Coppersmith <br />J..�. V !rV V <br />17 MOTHER <br />19a INFORMANT - NAME <br />Chlora <br />FIRST <br />MIDDLE <br />00053 <br />MAIDEN SURNAME <br />Tatum <br />