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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTiF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL " - ON -FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST#T$TICS9EC?IOIV,- IIHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS i - V" _ m,
<br />DATE OF ISSUANCE
<br />JAN 2 6 2001 200100993 ANLEYS.OQPER
<br />- a4S51STANT STATEREA/S€RAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN_ _SERVICES ItINANCE AVD SUPPORT
<br />VITAL STATISTICS - _-
<br />CERTIFICATE OF DEATH -�
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />n
<br />i
<br />3. DATE OF DEATH (Mann. Day Year)
<br />Donald Arthur Rice
<br />Q
<br />O -i
<br />C�
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />e In
<br />6. DATE OF BIRTH ,AAoath Day. Year)
<br />mt
<br />1
<br />� D
<br />N
<br />C
<br />_
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />520 -28 -6383
<br />c� `,
<br />V-+
<br />Univeristy of Nebraska Medical Center
<br />F DOA ❑ Other(Spec,fv)
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />0makra
<br />c�
<br />Douglas
<br />C) T
<br />O
<br />9c. CITY TOWN OR LOCATION
<br />9d. STREET AND NUMBER Ildcl ding Zrp Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />CD
<br />Alda
<br />305 W. 3rd
<br />Yes 2] No ❑
<br />10. RACE - le.g., While. Black. Amencan Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican. German. etcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /I/ wda give maiden name)
<br />rn
<br />(SpeaM
<br />American
<br />cu
<br />O
<br />10a. USUAL OCCUPATION /Give kind of work done during most
<br />OQ urk
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary or Sec ry 10 121 College it .4 o, i
<br />i�
<br />D
<br />Construction Company
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />�17
<br />Delbert Rice
<br />Willa Mildred Warren
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19A INFORMANT - NAME
<br />(Yes no or unk.) IIt yes. give war and dales of se -cesl
<br />Yes: K can 2 -5 -1952 1 -21 -19541
<br />Lauretta Rice
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F D NO_ CITY OR TOWN STATE. ZIP)
<br />305 West 3rd, Alda, NE. 68810
<br />-,
<br />OQ
<br />21b. DATE 21c.
<br />(j\
<br />®Bur a1 ❑Removal
<br />r-
<br />CD
<br />2FZa' FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑ Cremation ❑ Donator
<br />Grand Island. NE.
<br />V�
<br />C:D
<br />1123 West Second, Grand Island, NE. 68801
<br />CL7�
<br />PART /f
<br />DUE 10. 08 A6 A CONSEOU NCE�O"F Interval between onset and dean
<br />_" /
<br />b1 � c- �(.E- T , I�,"/ )� -v' E ✓1 -
<br />C.0
<br />N
<br />W
<br />,
<br />L2
<br />=zv
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTiF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL " - ON -FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST#T$TICS9EC?IOIV,- IIHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS i - V" _ m,
<br />DATE OF ISSUANCE
<br />JAN 2 6 2001 200100993 ANLEYS.OQPER
<br />- a4S51STANT STATEREA/S€RAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN_ _SERVICES ItINANCE AVD SUPPORT
<br />VITAL STATISTICS - _-
<br />CERTIFICATE OF DEATH -�
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />Z SEX
<br />3. DATE OF DEATH (Mann. Day Year)
<br />Donald Arthur Rice
<br />Male
<br />December 22, 2000
<br />4. CITY AND STATE OF BIRTH llf not in USA.. name country)
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH ,AAoath Day. Year)
<br />SD MOS I DAYS
<br />5c. HOURS MINS
<br />Dunning, Nebraska
<br />Vrsl 73
<br />April 27, 1927
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />520 -28 -6383
<br />HOSPITAL. ® Inpatient OTHER El Nursing Home
<br />7 ER Outpatient F� Residence
<br />8b. FACILITY - Name fit not Insr/tueon, give street and number)
<br />Univeristy of Nebraska Medical Center
<br />F DOA ❑ Other(Spec,fv)
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />0makra
<br />Yes K No ❑
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />90 COUNTY
<br />9c. CITY TOWN OR LOCATION
<br />9d. STREET AND NUMBER Ildcl ding Zrp Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Alda
<br />305 W. 3rd
<br />Yes 2] No ❑
<br />10. RACE - le.g., While. Black. Amencan Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican. German. etcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /I/ wda give maiden name)
<br />etc./ lSOecaty
<br />White
<br />(SpeaM
<br />American
<br />N EVER DIVORCED
<br />Lauretta Barnes
<br />10a. USUAL OCCUPATION /Give kind of work done during most
<br />141. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary or Sec ry 10 121 College it .4 o, i
<br />i�
<br />of working life, even if retired/
<br />Laborer
<br />Construction Company
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />�17
<br />Delbert Rice
<br />Willa Mildred Warren
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19A INFORMANT - NAME
<br />(Yes no or unk.) IIt yes. give war and dales of se -cesl
<br />Yes: K can 2 -5 -1952 1 -21 -19541
<br />Lauretta Rice
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F D NO_ CITY OR TOWN STATE. ZIP)
<br />305 West 3rd, Alda, NE. 68810
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />®Bur a1 ❑Removal
<br />Dec. 27, 2000
<br />Westlawn Memorial Park
<br />2FZa' FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑ Cremation ❑ Donator
<br />Grand Island. NE.
<br />221. FUNERAL HOME ADDRESS (STREET OR R .D NO CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND (0) Interval between onset and neat
<br />PART /f
<br />DUE 10. 08 A6 A CONSEOU NCE�O"F Interval between onset and dean
<br />_" /
<br />b1 � c- �(.E- T , I�,"/ )� -v' E ✓1 -
<br />' uue I u un ,ao'i 1.�rvoewerv�c u, - :nle�va� oer_ween ;ysee,_�„ star.
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but riot related PART
<br />PART PREGNANCY
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'S
<br />II
<br />(Ages 10 -Sd) yes NO
<br />Y95 No
<br />Vey No
<br />26a
<br />26b. DATE OF INJURY (MO.. Day. Yr)
<br />26c HOUR OF INJURY
<br />261. DESCRIBE HOW INJURY OC URRED
<br />Accident � Undetermined
<br />M
<br />Suicide R Pending
<br />Homicide Investigation
<br />26e. INJURY AT WORK
<br />Yes O No
<br />26f. PLACE QF. INJURY - At home. farm, street. factory
<br />o8ice budding. etc /Specify)
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH Iii Day. Yc)
<br />28a. DATE SIGNED (Mo.. Day. Yr I
<br />28b TIME OF DEATH
<br />$ rU7,
<br />LIE
<br />°
<br />a
<br />12/22/2000
<br />i
<br />$ r
<br />__�
<br />°
<br />M
<br />27b. DATE SIGNED (Mo.. Day Yrl
<br />27c TIME OF DEATH
<br />0315AM M
<br />28c. PRONOUNCED DEAD IMO.. Day, Ycf
<br />28d. PRONOUNCED DEAD IHoun
<br />M
<br />27tl To the best of m nowledge. curretl at time, date antl place and due to the
<br />28e On the basis M examination and Or investigation, in my Opm10n death occurred at
<br />causelsl stated.
<br />a
<br />the time, date and place and due to the causelsl stated.
<br />(Signature and Title
<br />(Signature and Title
<br />29. DID TOBACCO USE CONT UTE T DEATH?
<br />30e HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES "y0,. 0 UNKNOWN
<br />El YES R NO
<br />YES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />,I
<br />J .
<br />Sc Cv°r /VX= Lc1,�ffIX/��� 99S'I ?I A Yz62}jkj OYCgc CE, L-o�,4- 41w7yi4 N/
<br />32a. REGISTRAR
<br />a�� /
<br />321. DATE FILED BY REGISTRAR (Mo., Day. Yc)
<br />1 4 2001
<br />AS
<br />UA
<br />Part of Block 4 in Browns Addition to Aida, Hall County, Nebraska, described as
<br />beginning at a point on the north line of said Block 4 a distance of 125 feet east
<br />of the Northwest corner of said Block 4, thence southerly parallel to the west line
<br />of said block 4 a distance of 150 feet, thAnoe easterly and parallel to the northerly
<br />line of said Block h 2 distance e4 714 feet- thence nnrtherly anrinarmlIal to thaw
<br />`a
<br />
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