Laserfiche WebLink
M n n <br />T n z <br />c <br />N N <br />UAW <br />' <br />�1 T <br />WHEN THIS COPY CAAWS THE RAISED SEAL OF THE NEBRASKA HEALTH A <br />SYSTEK IT CERT]FES TIE BELOW TO BE A TRUE COPY OF THE OR/G/NALA <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$�C <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />MAY 2 8 1997 ASSIstAO <br />LINCOLN, NEBRASKA_ _ _ HEALTH AND HUM0 <br />STATE OF NEBRASKA - DEPARTMENT OF HE <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />0 <br />M <br />c> <br />c) <br />"I r <br />M <br />M <br />0 <br />►-a <br />CAD <br />(M <br />C-> cn <br />O --i <br />c v <br />a m <br />-i <br />-G O <br />O 'r► <br />'n z <br />x M <br />D 03 <br />r � <br />r- 3> <br />En <br />N <br />96 15643 <br />- - - - - -- • -• - -•� rmai MIDDLE LAST 3. DATE OF DEATH /Monts Day. Year/ <br />Mildred Edith McGrath male December 31, 1996 <br />;SEX <br />BIRTH /dnorh USA. name dolatey/ 58. AGE • Laet &roxlay UNDER 1 YEAR ER 1 DAY 6. DATE OF BIRTH /Morley, Day, Y,a,J <br />Brighton, Iowa '� (Yrs.l 86 sb. MOS. I DAYS SI MINS. <br />7. SOCIAL SECURTIY NUMBER O August 02 , 1910 <br />Be. PUCE OF DEATH <br />508 -60 -0631 HOSPITAL ❑ Inpatient OTHER: Nursing Horne <br />11b. FACILITY - Name . y'Hnd ku6krapn, pw preen and nwnber/ ❑ ER ONps rem ❑ Residence <br />Hearthstone Nursing Home, ❑ DOA .•- ❑ Othe (may <br />j <br />Sc. CRY. TOWN OR LOCATION OF DEATH <br />York Yes ❑ No [j York - <br />9a. RESIDENCE -STATE tiD. COUNTY ' " EET AND NUMBER (WuWnpZp Cone/ W.7rMSnOi Gll' Urn/lTS <br />Nebraska York York Lincoln'Ave. 68467 Yw ® No ❑ <br />=2319 <br />10. RACE - (e.g.. While. Black, American Inctan. 11. ANCESTRY (e,g.. flatten. Mexican, Gamun, etc) 12 ❑ MARRIED ® WIDOWED 13.' NAME OF SPOUSE (N wells #" Median homy <br />etcd ISpecity) <br />ISP*City) NEVER <br />White American O DIVORCED Dr. William McGrath <br />14a. S� 0 ft e T � / rw kind d wok done olaNry most 1 4b. KIND OF BUSINESS INDUSTRY 1 S. EDUCATION (SPeciy 0niy o <br />Of <br />(�, (0�\ <br />Homemaker `` �~ Elementary or Beeorltlery (0.12( Cottage 11.4 0,5-) <br />Domestic 4 <br />18. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Edward C. Castell Edith Mae Lechner <br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? 9a. INFORMANT -NAME <br />(Yes, no. Of unit( IN yea. give war and dates of ssrvksal <br />[William <br />No McGrath Jr. <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) <br />6212 Braeburn Circle, Edina, Minnesota 55439 <br />20. EMBAL - *NATURE ICE <br />21 a. METHOD OF DISPOSITION <br />21b. DATE <br />OR CREMATORVNAME <br />Jan. 4, 1997 <br />�cCEMETERY <br />Island Cemetery <br />22a. UNERAL HOME - E <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel- Butler- Geddes <br />❑ CreAation ❑Donaboh <br />Grand Island NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, NE 68801 -5899 <br />23, PART IMMMATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) I Interval belween or" and death <br />I <br />I(al Hypostatic pneumonia 1 week <br />I <br />DUE TO, OR AS A CONSEOUENCE OF: I Interval between onset end death <br />m) Severe multi- infarct dementia 10+ years <br />DUESO..QR <br />Cerebral and generalized arteriosc erosiss <br />(ol <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contir butt g b t e death but not related PART <br />III IF FEMALE. WAS THERE A <br />24. AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />11 PREGNANCY <br />None <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />(Ages <br />10 -54) Yea No <br />Yes No X <br />Yes, No KI <br />26a. <br />glib. DATE OF INJURY /Mo.. Day. Yr.) <br />260. HOUR OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />Accident � Undetermined <br />126d. <br />M <br />Suicide Pending <br />260. INJURY AT WORK <br />26f. PLACE QF INJURY, hoddne, farm, steel factory <br />W. bxlarh9, SIC SOaeel'J <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ NO ❑ <br />27a. DATE OF DEATH (MO.. Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />28b. TIME OF DEATH <br />a <br />December 31, 1996 <br />9:55 P M <br />s <br />C y <br />27b. DATE SIGNED (MO.. Day. Yr) <br />27c.- TIME OF DEATH <br />26c. PRONOUNCED DEAD (MO.. Day. Yr.) <br />M. PRONOUNCED DEAD (Howl <br />.January 3, 1997 <br />9:55 P M <br />- <br />M <br />s <br />s <br />~ <br />270. 7o the best of my knowledge. met - Sme, tlete and place and due to the <br />289. On tte basis of examination and/or investigation, in my opinion death occurred et <br />cause(s) stated. <br />v 6 <br />the time. date and place and due to the cause(s) stated <br />nature and Title <br />(Signature and Title <br />USE CONTRIBUTE T E AS TH? H ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />'TOBACCO <br />� <br />❑ YES ❑ NO UNKNOWN El YES ® NO <br />i <br />El YES ® NO <br />- <br />Carroll J. Loschen, MD,�York Medical flinic 2101 Lincoln York. NE 68467 <br />::rte <br />