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200009444
<br />WHEN TFNS COPY CAMMS 711 "MISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTMS THE BELOW TO BE A TRUE COPY OF THE OR 1GIN4L4W{QVa-0ffFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STgi J 911FWWICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE '
<br />JAS[ 3 12000,
<br />STINT STATEREWMAR
<br />LINCOLN, NEBRASKA HEALTH A1#MW4N SERVICES SYeEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMASE�_ & Akl AbIff§UPPOI
<br />vTTAL STATISTicS
<br />CERTIFICATE OF DEA n � ,A. _
<br />I DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month. Day Year)
<br />Rollin Wa
<br />e O'Neal
<br />Male I
<br />January 8 2000
<br />4. CITY AND STATE OF BIRTH /n not in U S.A.. name countryl
<br />�11
<br />IN THE PAST 3 MONTHS?
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Marts. Day Year)
<br />Sb MOS DAYS
<br />Sc. HOURS INS
<br />26a
<br />M
<br />f1
<br />n
<br />reth, Nebraska
<br />o
<br />H
<br />�
<br />�
<br />Ba. PLACE OF DEATH
<br />c
<br />m
<br />�
<br />Name (if not ristiMron, give street and number)
<br />o
<br />o
<br />N OR LOCATION OF DEATH
<br />28a. DATE SIGNED (Mo. Day. Yr I
<br />Btl. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />n
<br />z
<br />Yes [ No
<br />Hall
<br />Be RESILIENCE - STATE
<br />9b. COUNTY
<br />27b. DATE SIGNED /Mo. Day Yr l
<br />N�
<br />Z
<br />INSIDE CITY LIMITS
<br />Nebraska
<br />m
<br />TGrand I
<br />1 West 19 th 68 01
<br />i-90,
<br />Yea 9 No
<br />�, ~
<br />11. ANCESTRY is .. Italian, Mexican. German, etcl
<br />o
<br />�
<br />etc.) ISPeidyl
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />CDn
<br />14a. USUAL OCCUPATION IGrve kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />M
<br />Ele em r Secondary I 12) College 11.4 or 5.1
<br />m1 Grace
<br />of working life, even d retired!
<br />Clerk
<br />(Signature and Title ►
<br />M
<br />16 FATHER - NAME FIRST MIDDLE
<br />A
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Gyms NMI
<br />O'Neal
<br />Happy NMI Oale
<br />_
<br />18. WAS DECEASED EVER IN U 5. ARMED FORCES?
<br />a `�;
<br />o
<br />o
<br />C �,
<br />Henrietta O' Neal
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />04West 19th Street Grand Island Nebraska
<br />J E M T t
<br />l OD'
<br />b DATE 21c
<br />CEMETERY OR CREMATOR 1n ^AME to
<br />- 10,3 %
<br />z
<br />y
<br />Memorial Park
<br />22 FUNERAL HOME •NAME'
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Ir
<br />n Cremation El Donauor
<br />Grand Island Nebraska
<br />m
<br />3213 W. North Front St., Grand Island, Nebraska 68803 _
<br />m
<br />n CC)
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<br />-V
<br />r ' • T V-
<br />rb
<br />I Interval between onset and seam
<br />a
<br />G� N `
<br />(A s t c/t fit, �4SF �_ /Sxe 1144
<br />(b)
<br />.ors
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<br />z
<br />200009444
<br />WHEN TFNS COPY CAMMS 711 "MISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTMS THE BELOW TO BE A TRUE COPY OF THE OR 1GIN4L4W{QVa-0ffFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STgi J 911FWWICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE '
<br />JAS[ 3 12000,
<br />STINT STATEREWMAR
<br />LINCOLN, NEBRASKA HEALTH A1#MW4N SERVICES SYeEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMASE�_ & Akl AbIff§UPPOI
<br />vTTAL STATISTicS
<br />CERTIFICATE OF DEA n � ,A. _
<br />I DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month. Day Year)
<br />Rollin Wa
<br />e O'Neal
<br />Male I
<br />January 8 2000
<br />4. CITY AND STATE OF BIRTH /n not in U S.A.. name countryl
<br />�11
<br />IN THE PAST 3 MONTHS?
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Marts. Day Year)
<br />Sb MOS DAYS
<br />Sc. HOURS INS
<br />26a
<br />26b DATE OF INJURY /Mo.. Day. Yr.)
<br />(Yrs.)
<br />26d, DESCRIBE HOW INJURY OCCURRED
<br />reth, Nebraska
<br />79
<br />Jan 11 1920
<br />URTIV NUMBER
<br />Ba. PLACE OF DEATH
<br />rSCICIAL
<br />03 -4574
<br />26g. LOCATION STREET OR R F.O. NO. CITY OR TOWN STATE
<br />HOSPITAL Inpatient OTHER E] Nursing Home
<br />-
<br />ER Outpatient ER Residence
<br />Name (if not ristiMron, give street and number)
<br />West 19th Street
<br />0OA Oar (spec*
<br />N OR LOCATION OF DEATH
<br />28a. DATE SIGNED (Mo. Day. Yr I
<br />Btl. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />a i
<br />Yes [ No
<br />Hall
<br />Be RESILIENCE - STATE
<br />9b. COUNTY
<br />27b. DATE SIGNED /Mo. Day Yr l
<br />. TOWN OR LOCATION - ' - -
<br />9d. STREET AND NUMBER JhVAxalg Zip Cadet
<br />INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />TGrand I
<br />1 West 19 th 68 01
<br />i-90,
<br />Yea 9 No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY is .. Italian, Mexican. German, etcl
<br />12. a MARRIED ❑ WIDOWED
<br />t 3. NAME OF SPOUSE /ll wile. give maiden name)
<br />etc.) ISPeidyl
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />Henrietta Ellsworth
<br />14a. USUAL OCCUPATION IGrve kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION 'ISpealy only highest grade completed)
<br />Ele em r Secondary I 12) College 11.4 or 5.1
<br />m1 Grace
<br />of working life, even d retired!
<br />Clerk
<br />(Signature and Title ►
<br />Transportation
<br />16 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Gyms NMI
<br />O'Neal
<br />Happy NMI Oale
<br />_
<br />18. WAS DECEASED EVER IN U 5. ARMED FORCES?
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type- a 16 f)
<br />19a INFORMANT - NAME
<br />IYes. no. or unk.) III ye` give war 3no dates M servlcas)
<br />IL _
<br />32b DATE FILED BY REGISTRAR (M0. Day Yr.)
<br />Henrietta O' Neal
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />04West 19th Street Grand Island Nebraska
<br />J E M T t
<br />l OD'
<br />b DATE 21c
<br />CEMETERY OR CREMATOR 1n ^AME to
<br />- 10,3 %
<br />®cen ❑ t Removal
<br />Jan. 12 2000 W
<br />Memorial Park
<br />22 FUNERAL HOME •NAME'
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />n Cremation El Donauor
<br />Grand Island Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front St., Grand Island, Nebraska 68803 _
<br />23. IMMEDIATE CAUSE
<br />fENTE/R4/O'NLLY ONE CAUSE PER LINE FOR Tai. Ib), AND (c)) I Intgrval between onset and death
<br />/� ♦Y
<br />PART Ial �I •S/) �
<br />r ' • T V-
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />I Interval between onset and seam
<br />a
<br />G� N `
<br />(A s t c/t fit, �4SF �_ /Sxe 1144
<br />(b)
<br />.ors
<br />i
<br />1
<br />UUE 1Q, OR AS A CONbFQUt;N(;E (N"
<br />`OTHER
<br />SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />�11
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages 10 -54) Vey No
<br />Ves No
<br />Vey D No
<br />26a
<br />26b DATE OF INJURY /Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d, DESCRIBE HOW INJURY OCCURRED
<br />Acudent Undetermined
<br />M
<br />Suicide F] Perd,ng 26e. INJURY AT WORK
<br />261. PLACE OF. INJURY - qqt home. farm. street factory
<br />26g. LOCATION STREET OR R F.O. NO. CITY OR TOWN STATE
<br />Homicide Invesugai,on Yes[:] No
<br />❑❑
<br />o ice building, etc (Specdy)
<br />2 -a. DATE OF DEATH (MO. Day Yr)
<br />28a. DATE SIGNED (Mo. Day. Yr I
<br />28b TIME OF DEATH
<br />a i
<br />M
<br />8 i
<br />27b. DATE SIGNED /Mo. Day Yr l
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo. Day, Yr)
<br />28d. PRONOUNCED DEAD (Haul
<br />19:19 M
<br />1,1
<br />M
<br />27d To the best of my knowledge tl ath u at Bte time, data a- Wace and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death Occurred at
<br />.2
<br />causels) stated
<br />the time, date and piece and due to the dausels) stated.
<br />IS nature and Title ►
<br />(Signature and Title ►
<br />29 p0 TOBACCO USE CONTUTE TO THE DEATH?
<br />ORGAN OR TISSUE DONATION BE
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />7HAS
<br />YES NO O UNKNOWN
<br />El YES
<br />NO
<br />YES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type- a 16 f)
<br />David R. Colan MD 729 N. 04Wr, Gr Wland Nebraska 68803
<br />32s REGISTRAR
<br />32b DATE FILED BY REGISTRAR (M0. Day Yr.)
<br />•
<br />JAN 2 6 2
<br />Q
<br />
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