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1 DECEDENT - NAME P61ST MIDDLE LAST <br />Betty Jane Frohling <br />2 SEX <br />Female <br />UNDER I DAY <br />3 DATE OF DEAT,4 .Mu,,: Oi, YaNI <br />April 19, 2000 <br />16. DATE OF FIRTH Abaft Da. Yarl <br />a CITY AND STATE OF MATH Wargo LDS A. nanscaMleal <br />Campbell, Nebraska <br />Sa. AGE •Lae BRMay <br />(Yral 72 <br />UNDER 1 YEAR <br />55 MOS I DAYS <br />Sc . HOURS MANS I August 1 7 / 1927 <br />M i <br />7 SOCIAL SECURTR• NUMBER <br />506 -52 -3168 <br />em PLACE OF DEATH <br />�A� ❑ <br />• <br />0 <br />alp. o�HER NAa� .+o�a <br />ER OWpMOnt 0 Raided. <br />°°A 0 01Ae s°"` <br />BD. FAGUTY•Ntato arVlrtO.aal p0raaaa2ado nwWST <br />Health & Rehab Care Center <br />x CITY. TOWN ON LOCATION OF DEATH Be INSIDE CITY LIMITS Be COUNTY OF DEATH <br />Grand Island yes 1 Nb ❑ I Hall <br />9a. RESIDENCE • STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />Sc CRY. TOWN OR LOCATION <br />Grand Island <br />Ed STREET AND NUMBER NncNW19Z6 COOd ( 90 INSIDE CITY LAOS <br />1405 W. Hwy. #34 68801 ! .4 31.0 <br />TO RACE - (... WNe. Black Arlw¢an H6.n <br />M.l 1$bacayl White <br />1I. ANCESTRY 69 MM. Ma1Can. Daman. Mn I12 Li IIAARRIED . WIDOWED <br />ISWC9II American 1 1 II NEVER . ■ DWORCED <br />13 NAME OF SPOUSE rA*.. pa* modem +WM! <br />Dallas Frohli .• <br />1L. USUAL OCCUPATION laws llyddy5aaa mar *dlrr,D mc6r 145 <br />KIND OF BUSINESS INDUSTRY <br />Restaurant <br />t5 EDUCATION 155604 arey 15g5aagrade Cpnrpl4AaM <br />e/adHrg AR went/amp <br />Housekeeping /Cook <br />E a SamMW f0.121 <br />b r"j" WHOP '' • 0. 5 <br />18. FATHER -NAVE FIRST MIDDLE LAST <br />Herman Bartels <br />IT MOTHER FIRST MDDI lMDEN St1RNITME <br />Gteli Grams <br />to WAS DECEASED <br />,Yaa. T.�l/MI.) <br />EVER IN U S. ARMED FORCES? <br />I ayaa.q+w.aaMdaes <br />190. INFORMANT • NAME <br />Dallas Frohling <br />INFORMANT <br />195 OR MANT MAANG ADDRESS (STREET ORRFO NO. CITY OR TOWN. STATE. ZIP( <br />118 Cherokee Ave., Grand Island, Nebraska 68803 <br />� 2 7 r - t .,1 ! - <br />' / L ''"I % <br />21a. METRCDOFOfspOSRI <br />!i1 Baba • Removal <br />215. DATE 1 21c CEMETERY OR CREAM ?Oar +'AU.e C eme t ery <br />April 22, 2000} Campbell Presbyterian <br />UNERAL NOSE - N <br />Apfel- Butler - Geddes <br />❑ n ❑ D <br />215 CEMETERY OR CREMATORY LOCATION City OF TOWN STATE <br />Campbell, Nebraska <br />225 FUNERAL NOW ADDRESS IS MEET OR RFD NO CRY OR TOWN. STATE. ZIP) <br />1123 West Second, Grand Island, NE 68801 <br />IMMEDIATE CAUSE INTER ONLY ONE 1 USE PER um ISL AND (ell ! Norval baaean Moe and dean+ <br />lal <br />DUE TO.OR OUENCE OF <br />Inorval Whew onset ado dealt( <br />_ DUE TO OP AS SEGUE aner.41 Petbeen 05001 and army <br />~ - -_ <br />OTHER SIGNIFICANT CONDITIONS - C5N+aons . - 2" "n <br />P <br />L � � ` ` ,/T ` ' d <br />N 1 t ,� i <br />e- <br />.., IS IF FEMALE WAS THERE A y a AUTOPSY WAS CASE REFERRED TO MEDICAL <br />FREGNANCY IN ThlE PAST 3 MONT HS' /r \ �p EXAMINER OR CORONER' <br />4�,a <br />(Ages 10.541 Yes No 1/ ��� I Y5 n No 1 / � ( Yes n No 1/5(7 <br />'7 `01_7• <br />230 <br />O Accart I] UndMent Sd <br />0 Same 0 Randal.; <br />cme sbga5on <br />II Ham Nve <br />265 DATE OF INJURY . Day Er) <br />265 HOUR OF *QUR`r <br />I M <br />T?95 DESCRIBE HOW INJURY OCCURRED <br />f <br />285 INJURY AT WORN 261 PLACE o" Y _, 1arm sees! Iatbry 1 26g LOCATION STREET OR RFD NO CITY OR Too" STATE <br />Yes D No II dikcae s rh 9i <br />27a DATE OF OFJITH IAb. OW.. vii 7 280 DATE SIGNED , PA , !`av v f Talb TIME OF DEATH <br />i APRIL 19, 2000 Ia k, ' M <br />77b DATE SIGNED (MY Day W./ ?R TIME OF DEATH , tr I ?9c PRONOUNCED °FAD -4k+ Da. Yr: %, 2.c PAOrraRI 11 l DEAD JAN•• <br />APRIL 19,2000 12: _ A M I € z i ` M <br />. 1 d To ae ens 0/ my', acts annex e , • r 25e On me baills e■aeyrom and s <br />Caaaa MOM ` d a+ e cadges. n my doeon deal c: r..r»o a <br />6. wo e�t0Mace drJldue p ex le taJx�s .aMee <br />I • and TAO) r ; r the NM. <br />SVnaIWe and Tree ;, <br />c'. DD TOBACCO USE CONTRIBUTE TO THE CcAT$) HAS ORGAN OR TISSUF :ZONATION FEIN CONSIDERED' f Nth WAS CONSENT WANTED" <br />■ YES ■ NO UNKNOWN I YES J]f7'I NO 0 YES 0 NG <br />JJ <br />S1 NAME AND ADDRESS OF CERTIFIER 'PHYSICIAN CORONERS PHIYSICIAN OR COUNTY ATTORNEY, , TI115 or POW <br />W. J. Landis M.D. 2444 W., Faidlev, eGran Island, NE 68803 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARIMEN <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF 01 . <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SEKV. <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. .._.. j <br />DATE OF ISSUANCE <br />JUL 01 2015 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />STAN LEI PER <br />ASSIST NrSt A REGISTRAR <br />"' (DEPARTMENT: OF HEALTH i5ND <br />326 DATE FILED SY IIE(,ittjpE 16 <br />201504533 <br />Ror AND <br />If q ON <br />CADS', <br />r <br />1 <br />STATE OP NEBRASKA DBPAR7' 1117' OF HEALTH AND HUNAN SERVICES FIINANOE+A!VDS�RF <br />VffAL STATISTICS <br />CERTIFICATE OF DEATH 00' <br />0 4 8 2 3 <br />