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WFEN TM COPY CARROS TM RAISED SEAL OF THE NEBRASKA <br />SYSTEM, IT CERTIFE:S TFE: BELOW TO BE A TRUE COPY OF THE OR16WAL AEMM <br />, <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECl10N� ftiLS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - <br />DATE OF ISSUANCE - <br />�Ot�R <br />JAN 2 0 2000 Ass1�� TATER-9QT�`.TMR_ <br />LINCOLN, NEBRASKA HEALTHANI)HUMA <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEO� _ _ SUP*RT <br />VITAL STATISTICS <br />rir D "ic; r A TV (l17 TIP A Ti-i _. --- - <br />I. DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH [Month. Da. Year) <br />Elda Elizabeth Mehl <br />Female <br />January 5, 2000 <br />4. CITY AND STATE OF BIRTH /anof in USA.. name countryt <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAV <br />6. DATE OF BIRTH /MOnlh. Day.[Yead <br />DAYS <br />Sc. HOURS MINS. <br />Rural Cimarron, Kansas <br />(Vr51 <br />79 <br />March 16 / 1720 <br />Ma <br />7. SOCIAL SECURTIY NUMBER <br />Be . PLACE OF DEATH <br />OTHER ® Nursing Home <br />❑ <br />513 -48 -1386 <br />HOSPITAL: Inpatient <br />M <br />ER Outpatient ❑ Residence <br />Bb. FACILITY -Name /Nnof institution, give street and number/ <br />Wedgewood Care Center <br />❑ DOA ❑ Other /SpenHt <br />Bc. CITY TOWN OR LOCATION OF DEATH <br />Bd INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />9a. IDENCE - 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 />:RACE <br />Hall <br />Grand Island <br />1121 W. 6th St. <br />Yes ® No ❑ <br />10. - (e.g., While. Black. American Indian. <br />11. ANCESTRY leg.. Italian. Mexican. German, elcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /d wde. give maiden name) <br />91cISDec4YlWhite <br />ISOecMI American <br />NEVER DIVORCED <br />Otto J. Mehl <br />II 4a USUAL OCCUPATION IGrve ktndol work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15 EDUCATION <br />lSpeuly Only highest glade completed) <br />Elementary q Secondary 10 -12) College 1a 4 or 5.1 <br />1 L G} <br />D/work/HJl f(SX mf Aer <br />jj <br />Domestic <br />16 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Pierre Collie Egbert <br />Bertha Francisco <br />• 18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />I (Yes nVjnk.1 I III yes give war and dales of samwesl <br />Otto Mehl <br />194. INFORMANT MAILIN3 ADDRESS (STREET OR H.F.U. NU., l:tt T UH I v `v a r n ­ u" <br />1121 West 6th St. , - Gr- a�n-d- Island, NE 68801 <br />EM ALMER - SIGNATURE a LICENSE NO. y l 1 / 21a. METHOD OF DISPOSITION 1 21b. DATE . 21 c. CEMETERY OR CREMATORY NAME <br />� •� lJ Jan. 10 2000 B[ON Mennonite Brethren <br />Burial ❑Removal <br />22. . FUNERAL H ME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler - Geddes ❑ cremation ❑ Donation Balko, OK <br />22D. FUNERAL HOME ADDRESS IS REE I OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, NE 68801 <br />r IMMEDIATE CAUS (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ittl AND (c)) Interval balvvnen onset anti cream <br />RT - <br />17 <br />(al I Interval between onset and death <br />DUE TO, OR AS A CONSEQUENCE OF <br />(b) i �' /r Uv`'"�' / �",�C�`/��VVI/�_.__a'T� f - - <br />Interval between onset and death <br />DUE TO. OR AS A CONSEQUENCE OF: <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to Me death but not related <br />PART III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED R 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 <br />Yes ❑ No r <br />26a, <br />TE OF INJURY /MO.. Day. Yc/ <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Ac1dM1 R Untlelernnned <br />M <br />Suicide Pending <br />726elNJURY AT WORK <br />261. <br />�Otli�9Je1RY �ASGe� Y, . farm. street. factory <br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />s No ❑ <br />oPLAe <br />H <br />28a. DATE SIGNED /Mo. Day Yr 1 28D TIME OF DEATH <br />27a. DATE OF DEATH / . Day. Yr.J <br />I /rz O <br />a� M <br />3< <br />27b. DAT SIGNED .. Day. Y11 27c. TIME OF DEATH <br />$�$ <br />< a 28c. PRONOUNCED DEAD (MO.. Day Yc) 28d. PRONOUNCED DEAD /HOUrI <br />D <br />IFS ( / 3 04 It1J5 1 Mwz� <br />M <br />27d To best of my knowledge. death occurred a Nrne, date and da a and due to the <br />Be. 2 On the basis of examination and nor the cauation, in my opinion death occurred at <br />° 6 the time, date and pace and due to the causels) stated. <br />cause(s) stated. ,!J <br />Si nature and Thief <br />(Signature and Title ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE D ? 30. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED <br />YES l NO ❑ UNK t NOlf <br />YES _Np YES NO <br />,p� <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSIOIAN, GUHONDH S rHTa hr - ­­ - -1-- ­-­- <br />Gordon Hrnicek M.D. 729 N. Custer, Gra Island, NE 68803 <br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR fAk. Day Ytl <br />/ JAN 18 2000 <br />M h;i. -Qs7 <br />