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_ 20000327+ Rev I 119T STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATR nF nFATu N c 0 O U yC C 0 O 2 O N E to X d) to U z W E 0 C W V � W n L LL CL 0.0 w O Q Z LL M Lo u, J�[�A�RT DUE TO. OR AS AICONSEOUENCE OF I Interval between onset and oeam Ib) 41 `! 6Exiims DUE i0. OR AS A CONSEQUENCE OF I Interval between onsn and seam I - OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death bud not related PART PART PREGNANCY It b V C�1y� I DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH iUvoth Dal Vasil 26a Truman John Peters Male December 25, 1999 Arcidera Undetermined a CITY AND STATE OF BIRTH tifiWin USA.. name country) Sit AGE -Lost Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH r4fariM. Dm Vearl Sb. MOS DAYS 5c. HOURS MINS. Homicide Invesflgalion Palmer, Nebraska (Yrs I 72 November 27, 1927 7 SOCIAL SECUR7IY NUMBER 8a. PLACE OF DEATH 289 DATE SIGNED (Afo. Day Yr I 506 -42 -4791 HOSPITAL Inpatient OTHER ❑ Nursing Home k /__9L -17 a 9 8 u b ❑ ER Outpatient ❑ Residence M Bb FACILITY . Name /lf not institution, give street and number/ 27c. TIME OF DEATH ` �O �^ M Saint Francis Medical Center ❑ DOA ❑ Other /SPec4i 27n To the bast W - M— Merlge d th me a "ate and plat aLLLddd due fo the uselsl slated t. J t \ 1 tVw S, nature and Thiel V ^ V\ \ ` ` Bc CIT, TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be COUNTY OF DEATH 30 b WAS CONSENT GRANTED' YES _NO Grand Island Yea ® No ❑ I Hall 9a RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER Ilnc /rukilgllp Codw 9e INSIDE CITY LIMITS Nebraska Hall I Grand Island 1217 E. 19th St. 68801 Yea ® No ❑ 10 RACE - (e g., White. Blark American Indian, 11. ANCESTRY Is g_ halian, Mexican. German, elcl t2. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE IN wile ow maiden namel etcI Soeofyl White ISpec,fyl American I NEVER DIVORCED 1 Donna Sehimmer M tea USUAL OCCUPATION /Grua krndof work done during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speclly only "st grade Complated) of working life, even It retired) Farmer Agriculture Elerne ❑Ith S V ra�e 21 College 11 �4 or 5.1 lz 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME ' Fred Peters Margaret Muhlber er IS WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes . no or unk I Ih yes. give war and dales of services) no ---- - - - - -- Donna Peters - Wife 19b INFORMANT MAILING ADDRESS I OR R.F.D NO., CITY OR TOWN. STATE, ZIP) 217 t St., Grand Island, Nebraska 68801 20 E FR - SIGNAT E ENSE�IQ 21 a. METHOD OF DISPOSITION 21b. DATE A 21c CEMETERY OR CREMATORY NAME ©Burial ❑Removal Dec. 28!F1999 Westlawn Memorial Park 22a FUNFRALt ME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston- Sondermann F.H. ❑Cremation ❑Donation Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 u, J�[�A�RT DUE TO. OR AS AICONSEOUENCE OF I Interval between onset and oeam Ib) 41 `! 6Exiims DUE i0. OR AS A CONSEQUENCE OF I Interval between onsn and seam I - OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death bud not related PART PART PREGNANCY It b V C�1y� III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? (Ages 10 -541 Yea No 0 I 2e AUTOPSY T 1 Yes n No 25. WAS CASE REFERRED TO MEDICAL ,,EXAMINER OR CORONER' Yes No 26a 26b DATE OF INJURY (Mo.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Arcidera Undetermined M Suicide Pending 26e, INJURY AT WORK 261. P EgppFF �y hpme LIOl , term. street. factory bu8dle9.JMRY 269. LOCATION STREET OR R F.D. NO. CITY OR TOWN STATE Homicide Invesflgalion Yes No ❑ Ice /N 27a DATE OF DEATH (Mo. Day. Vr.) 289 DATE SIGNED (Afo. Day Yr I 28b TIME OF DEATH �= n Y k /__9L -17 a 9 8 u b M 27b DATE SIGNED (Mo.. Day Vr) \� �� \\ 27c. TIME OF DEATH ` �O �^ M 26c. PRONOUNCED DEAD (MO. Day, Vr) 2Bd. PRONOUNCED DEAD /H—,r M 27n To the bast W - M— Merlge d th me a "ate and plat aLLLddd due fo the uselsl slated t. J t \ 1 tVw S, nature and Thiel V ^ V\ \ ` ` 288. On the basis of examination and a nvestgatI m my opngn death attuned at the time, date sM place and due to the causes) staled. nature and Title) 29 DID tOBACCO USE CONTRIBUTE TO THE DEATH? k/ YES NO UNKNOWN OWN 30.e HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 1:1 NO 30 b WAS CONSENT GRANTED' YES _NO Y. iv Tl f ypiff -11 z;15 Uo t- -4t, ti , 684-o-3 32a REGISTRAR ' I 32b. DATE FILED BY REGISTRAR (Alic, Day Yr.) FOR VITAL STATISTICS USE ONLY /'71� Q e G .- CLC1c..G- a- r,'lz%a�rc— ..tiG.1�i - _" ;:;Z %cam (�� -G • l% - __(