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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Pauline June Coppersmith <br />2. SEX <br />Female <br />3. DATE OF DEATH (Month. Day. Year) <br />October 27, 2003 <br />4 CITY AND STATE OF BIRTH /11 not in U.S.A.. name country) <br />Grand Island, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />70 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6, DATE OF BIRTH (Month. Day. Year/ <br />June 27, 1933 <br />5b. MOS. I DAYS <br />5c, HOURS' MINS, <br />7. SOCIAL SECURTIY NUMBER <br />- 505 -36 -3094 <br />8a. PLACE OF DEATH <br />HOSPITAL: _ Inpatient OTHER G; <br />❑ ER Outpatient ❑ <br />DOA ❑ <br />Nursing Home <br />Residence <br />other /Specify( <br />- 8b. FACILITY - Name (if not institution, give street and number) <br />Beverly Healthcare Lakeview <br />27a. DATE OF DEATH /Mo.. Day. Yr.) /'� <br />/ <br />A- V'� 9 - 0 i <br />, 8c. CITY. TOWN OR LOCATION OF DEATH - <br />Grand Island <br />8d. INSIDE CITY LIMITS <br />Yes Xl No ❑ <br />8e. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip Code / <br />420 E. 7th St. 68801 <br />9e. INSIDE CITY LIMITS <br />Yes Ea- No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />etc.( (Specify) <br />White <br />11, ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />(Specify) <br />American <br />12. ❑ MARRIED ;ice WIDOWED <br />NEVER :t DIVORCED <br />❑ MARRIED LI <br />13. NAME OF SPOUSE /II w ile. give maiden name) <br />Charles Coppersmith (Dec) <br />14a. USUAL OCCUPATION /Give kind of work done during most <br />. or working life, even it reliredl <br />Co -Owner <br />14b. KIND OF BUSINESS INDUSTRY <br />Tavern <br />15. EDUCATION )Specify only highest grade completed) <br />Elementary or Secondary (0 -12) College 11 -4 or 5 <br />11th Grade <br />16. FATHER - NAME FIRST MIDDLE LAST <br />Lewis Pohlman <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Alma Schmidt <br />- 18. WAS DECEASED <br />(Yes. no. or unk.) <br />No <br />EVER IN U.S. ARMED FORCES? <br />(11 yes. give war and dates of services) <br />19a. INFORMANT - NAME <br />Paula Nolte • <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F,D. NO.. CITY OR TOWN. STATE. ZIP/ <br />417 W. 9th St., Grand Island Nebraska 68801 <br />20. BALMER - SIGNATURE & LICENSE NO. <br />4.44-1 - 't . / 43 <br />21a. METHOD OF DISPOSITION <br />Ig Burial ❑ Removal <br />❑ Cremation I Donation <br />21b. GATE <br />Oct. 30, 2003 <br />210. CEMETERY OR CREMATORY NAME <br />Westlawn Memorial Park <br />22a. FUNERAL HOME - NAME <br />Livingston -Sondermann F.H. <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR RF.D, NQ.. CITY OR TOWN. STATE. ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE CAUSE /� ) n �d} a41 (ENTER ONLY ONE CAUSE PER LINE FOR (al. (5), AND (c)I I Interval between onset and death <br />1 A/-1 R <br />[ 1R (a( f' /K/"T /Zk Y • //�' 114. ' k kS <br />tc) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />II <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 I MONTHS? f <br />(Ages 10 -541 Ves I No Li I <br />24 AUTOPSY <br />Yes n No VI <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />X Yes n No7- <br />26a. <br />Ill Accident II Undetermined <br />11 Suicide a Pending <br />Homicide Investigation <br />265. GATE OF INJURY /Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />/ <br />26d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Ves ❑ ❑ <br />26f. PLACE QF - At home, farm. street factory <br />o ice bmldmg, eNO <br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE <br />To be Completed by <br />Attending PHYSICIAN <br />ONLY <br />27a. DATE OF DEATH /Mo.. Day. Yr.) /'� <br />/ <br />A- V'� 9 - 0 i <br />To be Completed by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />28a. DATE SIGNED (Mo.. Day. Yr) <br />285. TIME OF DEATH <br />M <br />28c. PRONOUNCED DEAD (Mo.. Day, 4.) <br />28d. PRONOUNCED DEAD (Hood <br />M <br />27b. DATE SIGNED (Mo.. Day. Yr.) . ,ems <br />.- / C/ r' P i'V / <br />27c. TIME OF DEATH <br />` J): (y{ � // M <br />28e. On the basis of examination and' or investigation, in m opinion death occurred at <br />9 Y W <br />/ (Signature nature and Title) the time, date and place and due to the sous* stated. <br />g to <br />27d. To the best of m know) th occurred at e time da d place and due to the <br />Y <br />twe nd <br />!Signature and Td. Title/ Or, t�f� <br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH? <br />Jr'''. YES ❑ NO ❑ UNKNOWN <br />30.a ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />4----- YES NO <br />30.5 WAS CONSENT GRANTED? \\ � <br />X ❑ YES �/�NO <br />31. NAM AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print( <br />X Vi c Z Ol i • 9 )i A- CU a r LG S /c � 1� � � � & 1 a <br />32a. REGISTRAR - l <br />1a <br />32b. DATA FILED BY REGISTRAR (Mo.. Day. Yr.) <br />OCT 362003 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION . WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />12/23/2003 <br />LINCOLN, NEBRASKA <br />DUE TO, OR AS A CONSEQUENCE OF. <br />t wJ!\ l'TA c <br />(Li v ti <br />DUE TO, OR AS A CONSEQUENCE OF <br />2015065 s <br />4 <br />VITAL STATISTICS <br />CERTIFICATE OF DEATFf <br />ANLEY S COOPER <br />ASSISTANT STA.TE REGISTRAR <br />HEALTH AND SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES Ffl!FANEE AND SUPPORT <br />03 12210 <br />Interval between onset and death <br />14Y <br />Interval between onset and death <br />