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I DECEDENT - NAME FIRST MIDDLE LAST n II 3. DATE OF DEQH_ _,Month Dar Pearl Dorothy Elizabeth Olson Female February 1, 2000 4. CITY AND STATE OF BIRTH /t not m USA. name couneyl i D n o n V) UNDER t DAY "T"t Sb MOS DAYS Sc. HOURS' MINS M N in rn rn (�' o 8a. PLACE OF DEATH ❑ Inpatient OTHER Nursing Home 506 -14 -0842 HOSPITAL. o C Iwo Tiffany Square ❑ DOA ❑ Other (Specify) Bc CITY TOWN OR LOCATION OF DEATH 80 INSIDES CITY LIMITS Be COUNTY OF DEATH •Grand__Ialand -__. IAi Nn ,all - V-- .M Ov 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (ine, ding Zp Code) Tge INSIDE CITY LIMITS C7 a7 N and Island 13119 W. Faidley Ave. � Yes ❑X No ❑ 10 RACE - leg., While. Black. American Indian. 11. ANCESTRY te.g.. Italian. Mexican, German, etc) t 2. ❑ MARRIED ® WIDOWED t 3 NAME OF SPOUSE lit wile. give maiden name; etc.)fSpectY) White (Specify) American NEVER DIVORCED o r- y. t n url cc 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) _ C Ca �K Olson 1 s Market 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Rolla C. Smith Elizabeth G. Hayes cll p O WHEN TIAS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUU%N1#)W0U0 SYSTEM R CERTIFE:S THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR'Q- ff THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS.SECTI011�wOo == G THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE -: 2000015s 1 5 2000 ASS/STAI tftATEREGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES.- fY#rEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICMFI?�.%NCE AM AWPOdlif VITAL STATISTICS CERTIFICATE OF DEATH I DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEQH_ _,Month Dar Pearl Dorothy Elizabeth Olson Female February 1, 2000 4. CITY AND STATE OF BIRTH /t not m USA. name couneyl 5a. AGE- Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH (Month. Day Year; Sb MOS DAYS Sc. HOURS' MINS Omaha, Nebraska (Yrsl 89 O`J, November 24, 1910 7 SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH ❑ Inpatient OTHER Nursing Home 506 -14 -0842 HOSPITAL. ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name ft not msNution, give street and number] Tiffany Square ❑ DOA ❑ Other (Specify) Bc CITY TOWN OR LOCATION OF DEATH 80 INSIDES CITY LIMITS Be COUNTY OF DEATH •Grand__Ialand -__. IAi Nn ,all - V-- .M 9a RESIDENCE - STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (ine, ding Zp Code) Tge INSIDE CITY LIMITS Nebraska Hall and Island 13119 W. Faidley Ave. � Yes ❑X No ❑ 10 RACE - leg., While. Black. American Indian. 11. ANCESTRY te.g.. Italian. Mexican, German, etc) t 2. ❑ MARRIED ® WIDOWED t 3 NAME OF SPOUSE lit wile. give maiden name; etc.)fSpectY) White (Specify) American NEVER DIVORCED M 14a USUAL OCCUPATION /eG�iv�e kind of work dare during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) _ Elementary q 2condary 10 -12) College 11 -a or S I of waking tile, every/]aA ier l.: Olson 1 s Market 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Rolla C. Smith Elizabeth G. Hayes 18 was DtctAStD tVtH IN DS. Arw 1VH for ' Ye r unk.) I I' ye- g; .;r and dalcs of services) Rolla S. Lush 1Bb. (JIFORMANT MAILING ADDRESS (STREET OR RE D. NO., CITY OR TOWN. STATE. ZIP) 3139 Woodridge Blvd. Grand Island, Nebraska 68801 20. : ER - SIGNATURE & LIC NO3 / 21a METHOD OF DISPOSITION 121b. DATE 21c CEMETERY OR CREMATOR- -W .ME 1' Burial ❑Remc,a, Feb. 7, 2000 —� Forest Lawn Cemetery _ a FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCAT,3N CITY OR TOWN STATE Apfel- Butler- Geddes ❑ Cramabon ❑Donation Omaha, Nebraska lib FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, Nebraska 68801 23 IMMEDIATE CAUSE (ENTER OPER L INE FOR lal. to). AND )q) Interval between onset and death PART /�. lal I DUE TO, OR AS A CONSEQUENCE OF Inlerval between onset and death I rol I CULL TO. OR AS A CON3EQUEt +CE OF .. '. " -- -- - : - -. r - Interval between onset and dean I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death Dut not related PART III IF FEMALE. WAS THERE A PART PREGNANCY IN THE PAST 3 MONTHS, 2a AUTOPSY ! 25.NJAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? II ' )Ages 10 -54) Yes No Yes No Yes No 26a 26b. DATE OF INJURY IMO. Day. Yr.) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED F-] Accident ❑ Undetermnned M Suicide Pending /tdhaicide .. - 1tlVashgation 26e. INJURY AT WORK Yes ❑ N, ❑ 26f PLLAqCE OF INJURY - At ". )arm, street. factory o6ice building, etc. lSpecry, - 26q. LOCATION STREET Oti R F D. NO. CITY OR TOWN STATE - 27a. DATE OF DEATH /MO.. Day Yr.) 28a DATE SIGNED (MO.. Dar. Yr i 28b TIME OF DEATH $ n r w�� ° O o8 M- 27b. DATE SIGNED fA4o.. Day Yr 27c TIME OF DEATH M 28c PRONOUNCED DEAD (Mo. Day. Yr .l 28d. PRONOUNCED DEAD (Hour! —.___— M 27tl To the best f my k letlge. death occurr t the time, ate and pace and due to the causets) stated. / -- / i 28e. On the basis of examination and 'or investigation, in my opinion death occurred at 81e time, dale and pace and due to the causelsl stated, Signature and Title 1` ISI nature and Titlel jo 29 DID TOBACCO USE CONTRIBUTE TO THE H? ❑ YES ❑ NO UNKN N a HAS ORGAN OR TISSUE DONATION BEEN COf181DERED? ❑ YES e NO 30.b WAS CONSENT GRANTED' ❑ YES ETINC, �1 rvM1Mt HrvU AUUHtJJ Vr VCniiriCn lrnl, n. Inrv, VVnVnCnJ rnlJn.,nlx vn .vvr,•n•,v.......r rw •^••^• Gordon Hrnicek M.D. 729 N. Cuqte h, Grand Island, NE. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR IMo., Day. Yr) PEB 112000 Lot Five (5), West Spelts- Schultz Addition to the City of Grand Island, Hall County, Nebraska, Being a tract of land comprising a part of the West Half of the Southeast Quarter (W 1 /2SE1 /4) of Section Twenty (20), m 1 • ri 11 1\ XT- I- TI_ -___ TT'___ 7f%% NIT__ _l'.l__ Lth T TA' -_ TT-11 f'i,,...,. , WT.1.. «..,I1