Laserfiche WebLink
-- n rn D rn o __q o <br />T cn m "'� r n O <br />o a <br />_ <br />M y "0 L r,- c::) d <br />Z3 r D o CSC <br />C..J <br />CC <br />GD Cn <br />Rev. 11197 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />2 0 0 0 3 9 4 CERTIFICATE OF DEATH <br />CC <br />O <br />O <br />U <br />CC <br />7 <br />O <br />U <br />O <br />N <br />C_ <br />E <br />rd <br />x <br />dt <br />al <br />U <br />Z E <br />W <br />p c <br />LLI Cu <br />U U <br />LIJ <br />L <br />LL 2 <br />I. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month Day. Year) O <br />Carol Ann Ro an <br />Female <br />June 21 2000 <br />4. CITY AND STATE OF BIRTH ignol ki U.S.A. name country/ <br />5a. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Year) <br />Sb. MOS. DAYS <br />Sc. HOURS' MINS. <br />26b. DATE OF INJURY /Mo.. Day. Yr.) <br />(Yrs.l <br />DUE TO.OR AS A COD <br />Fremont, Nebraska <br />49 <br />1 <br />December 10 1950 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH ZI <br />508 -64 -1838 <br />HOSPITAL: F, Inpatient OTHER: Nursing Home <br />E] ER Outpatient ❑ Residence <br />Bb. FACILITY -Name tit not rnslilrrlian, give street and number) <br />Park Place Health Care and Rehab Cent <br />❑ DOA ❑ Other /Specr/y1 <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY. LIMITS <br />Be. COUNTY OF DEATH <br />27a. DATE OF DEATH (Ma. Yr.1 <br />Yes ® No ❑ <br />Hall <br />Grand Island <br />�vvJV <br />M <br />DEAD <br />9a. RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />804 South Cherry, 68801 <br />Yea ® No ❑ <br />10. RACE -.g.. White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED F-1 WIDOWED <br />13. NAME OF SPOUSE !it wile. give maiden name/ <br />e1c.11SOecityl <br />(Specify) <br />NEVER DIVORCED <br />Wh 1 <br />MA I <br />14a. USUAL OCCUPATION (Give kind of ark done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary 10.121 College It -4 or 5.1 <br />olworkinglide, even !(retired! <br />Home Maker <br />D eSt3.r- <br />16. FATHER -.NAME FIRST MIDDLE LAST <br />t 7. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />18. WAS DECEASED EVER IN U.S. MED FORCES? <br />t9a. INFORMANT -NAME <br />(Yes. no. or unk.) (II yes. give war and dates of services) <br />No 1 <br />19b. INFORMANT MAILING ADDRESS ISTREET OR A.F.D. NO., CITY OR TOWN. STATE. ZIP <br />20. EMBA ER - SIGNATURE 8 UCENS O. IZ3& <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY • NAME <br />LM© <br />Burial ❑ Removal <br />06 -24 -2000 <br />Grand IslandCity Cemetery <br />22a. FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />❑ Cremation ❑ Oonalxxt <br />Grand Island, Nebraska <br />22 . FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />_ __ _._.___.__..._____...._.- ...._. .�. ......_,. I tore.., >th -an nnnm and death <br />0 M <br />23. IMMEDIATE CAU <br />LLI N <br />PART <br />2 <br />I <br />dal <br />Q <br />DUE TO, OR AS CON <br />Z lL <br />!Ages 10.541 Yes No <br />C6 <br />No <br />Ib) <br />26b. DATE OF INJURY /Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />DUE TO.OR AS A COD <br />DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />> rCSS/ o <br />OF: <br />I <br />1 <br />1 <br />I Interval between onset and death <br />I <br />I <br />I <br />I Interval between onset and death <br />I <br />Icl Lh, 0. J <br />OTHER SIGNIFICANT CONDITIONS - Condilions conlributin o the ealh but not aletl <br />PART III IF FEMALE WAS THERE A <br />I <br />24. AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />PART <br />PREGNANCY IN THE PAST 3 MONTHS? <br />11 <br />!Ages 10.541 Yes No <br />Yes No RI-Yei; <br />No <br />26a. <br />26b. DATE OF INJURY /Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />pt <br />126d. <br />Suicide ❑ Pending <br />26e. INJURY AT WORK <br />LLqq Epp INJURY %S��) , term. street. factory <br />ofaca <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />126L <br />building <br />27a. DATE OF DEATH (Ma. Yr.1 <br />28a DATE SIGNED dMa. Day. Yr.) 281b. TIME OF DEATH <br />)Day. <br />�vvJV <br />M <br />DEAD <br />27b. DATE SIGNED /Ma Daly. Yr.1 27c. TIME OF DEATH <br />t <br />28c. PRONOUNCED DEAD /MO.. Day, Yr.) 28d. PRONOUNCED /Hour! <br />r <br />M <br />1 1 M <br />8 <br />27d. Tole best of my kn ledge. death Occu t Iha 8me antl ce and due to the <br />F v 28e. On the basis of examination andtor investigation, in my opinion tleath occurred at <br />Dub <br />cause(s) staled <br />the lime. date and place and due to the causels) slated. <br />signature and Tillel ► r IS' nature and Title <br />29. DIO TOBACCO USE CON,(TRRIIBBUUTE TO DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br />❑ YES ),(I NO ❑ UN OWN 1:1 <br />YES NO ❑ ,YES NO <br />3t. NAM( ANU AUUMCJJ Ur I.CMItnCn tr'rIrJM11NY, tVnvrvcna rnrannnn vn a.vvnir nr,�nn..r rrr -•• <br />r. Gordon J. Hrnicek, 729 N. Custer, Grand Island, Nebraska 68803 <br />\t • MC 32b. DATE FILED BY REGISTRAR tAft. Day. Yn1 <br />at I BY C IFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORI INAL DEATH CERTIFICATE <br />100I E BUREAU OF VITAL STA fT COL OL <br />ISTI S I <br />EXPIRES ?T NEB KA. <br />* t <br />4, <br />?.'PS�� `r <br />qT£ 0 F NEB APFEL- UT _ -GE D S FUNERAL WOME <br />