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n n <br />ICJ n n Z i cn CD <br />2 D a 3 z -� ry M <br />M 2 N m --< C> Q <br />fi F_A O <br />` o o �t O <br />M^^ n w -n Z O Q. <br />b' m l O D Coo O y <br />at, p p a r D �'' cW <br />Cn co Cn Cn ca c <br />O CD <br />C,J (a co a <br />O� <br />0 z <br />m � <br />C <br />.. O <br />C) <br />c T� <br />a 2 <br />F- <br />4- <br />.� <br />J <br />4 N <br />o- <br />0 <br />4- <br />t o <br />o U <br />L <br />W 0 <br />3 � <br />O <br />0) <br />C O <br />Z T� <br />� 2 <br />0 <br />J r_ <br />4- M <br />O <br />\L_ <br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND-HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL OR&ON -HLE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TE B L` WHICH IS � <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />200001968 = _ 9C COOPER 1 0 2000 AS TAWrSM1 GfTft R <br />$ERM ESITEM LINCOLN, NEBRASKA HEALTH Aft -R WAE( <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN 5`�_ R� 'WE$ £#*1N5•AN!?3 WPORT <br />VITAL STATISTICS <br />CF- RTIFICATF OF DEATH <br />t DECEDENT - NAME FIRST <br />MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH /Month. Day Yearl <br />Gary <br />Fred Page <br />Male <br />February 2, 2000 <br />4 CITY AND STATE OF BIRTH ttl rpt in U S A.. name counlryl <br />(Ages 10 -54) Yes No <br />5a. AGE - Last Birthday F <br />UNDER t YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Yearl <br />Sb MGS DAYS <br />5c. HOURS' MIN$ <br />Grand Island, Nebraska <br />(Yrsl 59 <br />L -fit <br />May 1 1 3, 1940 <br />7 SOCIAL SECURTIY NUMBER <br />26e INJURY AT WORK <br />8a. PLACE OF DEATH <br />❑ Inpatient OTHER ❑ Nmsvng Home <br />508 -38 -0147 <br />Homicide Investigation <br />HOSPITAL <br />o ice etc. <br />❑ ER Outpatient L=' Residence <br />Bb. FACILITY - Name (H not institution. give street and number <br />Home: 21--K --West 11th <br />❑ DOA ❑ Other tSpecdVi -. <br />Sc. CI7 N OR LOCATION OF DEATH <br />Bel INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />F" <br />Yea ® Np ❑ <br />I Hall <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />3Ni <br />9c. CITY, TOWN OR LOCATION <br />9 STREET AND NUMBER /Including Zip Cale/ <br />9e INSIDE CITY LIMITS <br />Nebraska I <br />Hall <br />g } <br />a <br />Grand Island <br />2132 West 11th 68803 <br />Yes X❑ Np ❑ <br />10. RACE - Is %. White. Black. American Indian. <br />11. ANCESTRY (eg- Italian. Mexican. German, etc/ <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE Ill wde. give maiden name) <br />atc.l(Specify) White <br />Specify' <br />American <br />NEVER DIVORCED <br />Carol A. Fenton <br />° she <br />time. date and place and due to the causelsl stated. <br />MAR 1 <br />tae. USUAL OCCUPATION tGrve kind of work dare during most <br />. 6Po TOBACCO USE CONTRIBUTE T61fHE DEATH? <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elementary oryS ontlary l0 -121 Cdlege 11 4 or S• I <br />o, working li e. even it retired! <br />Self Employed <br />YES <br />Cleaning <br />18. FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Fred <br />�17 <br />Page <br />Matilda Dietring <br />11 wAS DECEASED EVER W U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yea no. w unk.) III yes. gr re war and dales of services) <br />No <br />Carol_ A. Page _ <br />sob IlPFORMANT MAILING ADDRESS <br />(STREET OR R.F.U. NO.. CITY OR TOWN. STA' E. ZIP) <br />2 32 West llt Grand Island, NE. 68803 <br />, <br />_7 <br />Z0. R - SIGNATURE & LICENS / <br />�f <br />!► <br />21 a. METHOD OF DISPOSITION <br />21[ DATE <br />CEMETERY OR CREMATORY NAME <br />Q Burial ❑ Removal <br />Feb. 5, 2000 <br />Grand Island Cemetery <br />FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes <br />❑ Dernalbn ❑ Donatron <br />r Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TCWN STATE, ZIP) <br />1123 West Second, Grand Island, Nebraska 68801 <br />23. IMM EDIATE C E .� <br />TER ONLY ONE CAUSE PER LINE FOR lal. Ibl. AND Icy Interval between onset and Beam <br />PART _ ^ 1 <br />(al �� <br />b <br />DUE TO. OR A A CONSIVUENCE OF <br />�lA <br />{ /� I Interval between onset and death <br />('/J/�' /�-- <br />�� <br />lW, <br />c • /(- <br />�� %�� � X V I <br />•� <br />Ft_ <br />I V <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEME. WAS THERE A <br />AL <br />24 AUTOPSY <br />WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />J25. <br />EXAMINER OR CORONER' <br />11 <br />(Ages 10 -54) Yes No <br />Yes No <br />Yes No <br />26a. <br />26b DATE OF INJURY tMo. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />nAccident F Undetermined <br />M <br />Smcrde n Pending <br />26e INJURY AT WORK <br />261. PLACE OF. INJURY - At hom , farm. street, factory <br />building. (Specifyf <br />26g. LOCATION STREET OR R F D. NO CITY OR TOWN STATE <br />Homicide Investigation <br />❑ ❑ <br />o ice etc. <br />Yes No <br />27a. DATE OF DEATH tMo. Day YrJ <br />28a. DATE SIGNED (Mo.. Day Yr 1 <br />281b . TIME OF DEATH <br />F" <br />M <br />y <br />3Ni <br />27b. DATE SIGN (Mid Day Yr) <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD tMo. Day, Yrj <br />28d. PRONOUNCED DEAD (Hourl <br />g } <br />a <br />5:00 a.m. <br />M <br />M <br />.° <br />R Y 6 <br />d To the best f my n e e. de occurr all twn ate and dace and due to the <br />28e. On the basis of examination and or investigation, in my opinion death occurred at <br />causelsl stated. <br />�lSiqnature <br />° she <br />time. date and place and due to the causelsl stated. <br />and Title <br />(Signature and Title ► <br />. 6Po TOBACCO USE CONTRIBUTE T61fHE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CON-•SIDERED? <br />30.b WAS CONSENT GRANTED' <br />❑ ❑ NO C;<NKNOWN <br />-4 6 <br />❑ YES W-46- <br />❑ YES Zj NO <br />YES <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type a Print/ <br />Sitki Copur M.D. 2115 W. Faidl Grand Island, NE. 68803 <br />32a. REGISTRAR AWA� <br />32b, DATE FILED BY REGISTRAR B � Da x2000 <br />V <br />