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1. DECEDENT - NAME FIRST MIDDLE LAST Connie Louise Hoffman 2. SEX Female 3. DATE OF DEATH (Month. Day. Year) June 2, 2003 4. CITY AND STATE OF BIRTH (2 not in U.S.A. name country) North Platte, Nebraska 5a. AGE - Last Birthday (YrS.I 49 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year May 12, 1954 5b. MOS. I DAYS I , Sc. HOURS MINS. 7. SOCIAL SECURTIY NUMBER 506 -70 -4573 8a. PLACE OF DEATH HOSP_ ITAL: ❑ Inpatient OTHER: ❑ ❑ ER Outpatient fl ❑ DOA ❑ Nursing Home Residence Other ISpecrtyr 86. FACILITY - Name (If not institution, give street and number) 2319 E. Stolley Park Road 28a. DATE SIGNED (Mo.. Day. Yr.1 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island ed. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Hall 17 Yes ❑ No X 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 2319 E. Stolley Park Road 68801 9e. INSIDE CITY LIMITS Yes ❑ No X 10. RACE - (e.g., White. Black. American Indian. etc.) (Specify) White 11. ANCESTRY (e.g.. Italian, Mexican, German, etc) (Specif American 12. MARRIED ■ WIDOWED NEVER r DIVORCED i MARRIED 1 13. NAME OF SPOUSE pf wile. give maiden name) John Hoffman 14a. USUAL OCCUPATION (Giveki of work done during most of waking life, even if refired( Registered Nurse 148. KIND OF BUSINESS INDUSTRY System Public School System EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -121 College It -4 or 5.1 12 4 16. FATHER - NAME FIRST MIDDLE LAST Jack Mogensen 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Gertrude Eggers 18. WAS DECEASED (Yes. no. or unk.) No EVER IN U.S. ARMED FORCES? (If yes. give war and dates of services( 19a. INFORMANT - NAME John Hoffman OTHER SIGNIFICANT CONOITfONS - Conditions contributing to the death but not related PART II PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? n 1`-1 (Ages 10 -54) Yes t l No � 24. AUTOPSY r Yes [ No F1/ 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER" Yes ' No 26a. IN Accident III Undetermined NI Suicide II Pending II Homicide Investigation 26b. DATE OF INJURY (Mo.. Day. W..) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW IN,;URY OCCURRED 26e. INJURY AT WORK Yes No ❑ ❑ 261. PACE OF. INJURY - At home, farm. street factory o ce bwldmg, etc. (Sp 26g. LOCATION STREET OR R.F.D. Na . CITY OR TOWN STATE - w U a0 27a. DATE OF DEATH (Mo.. Day. Yr.) June 2, 2003 r au z 8 a a 0 U2 } A 2 cc 8 ~ 3 28a. DATE SIGNED (Mo.. Day. Yr.1 28b. TIME OF DEATH M 27b. DATE SIGNED (Mo.. (Mo.. Day. Yr) 6 f ✓ 1 3 27c. TIME OF DEATH 8:25 A. M 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) (Hour] 28d. PRONOUNCED DEAD (Hour] M 27d. To the best of my knowledg eath oc ur at the �qr�1eee.,, date and place and due to the causels) stated. { - C ti.L+v r ISignature and Title) ). - "�. e f ( ,r' 28e. On the basis of examination and or investigation, in my opinion death occurred at the time, date and place and due to the causes stated. (Signature and Title/ ► 29. DID TOBACCO USE CONTRIBUT 0 THE EATH? ❑ YES NO ❑ UNKNOWN/ 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 30.b WAS CONSENT GRANTED? ❑ YES YO 196. INFORMANT 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 RECORD -ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SFr'TIOAt WEi1CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 6/10/2003 LINCOLN, NEBRASKA 21a. METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation ❑ Donation 21b. DATE June 5, 2003 20. BALMER - SIGNATURE & LICENSE (r/ MAILING ADDRESS STR ET R R.F.D. NO., CITY OR TOWN. STATE. ZIP) 2319 E. Stolley Park Road , Grand Island, Nebraska 68801 22a. FUNERAL HOME- NAME All Faiths Funeral Home 225. FUNERAL HOME ADDRESS 23. IMMEDIATE CAUSE � f'� (� n a (ENTER ONLY ONE pikUSE PER , LINE FOR la). 01, AND (c)) PART fa) t !Y � X7 V 4 � �! ' .� a Arc_ / \ \ `V i tQ _ i _( DUE TO, OR AS A CON OUENCE OP . _[ _ -- - DUE TO. OR AS A CONS 'DUEFCE OF: SiAMI. S. COOPER ASSISTA t4 PEGISTRAR HEALTH AND - HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESFINANCE AND SL*PORT VITAL STATISTICS - = - CERTIFICATE OF DEATH # 1071 (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 2929 S. Locust St., Grand Island, Nebraska 68801 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN Broken Bow, Nebraska ' 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORON S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 201505487 Sitki Copur M.D., 2116 W. Faidley Ave., Grand Island, Nebraska 68803 21c. CEMETERY OR CREMATORY - NAME Broken Bow Cemetery 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) 03 06393 STATE Interval between onset and death //no r Interval between onset and death Interval iween onset and death JUN 9 2003