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ECEDENT - NAME FIRST MIDDLE LAST Darlene,. Dawn 2 SEX Fema 3. DATE OF DEATH /Month Day Year) December 25, 2001 • Stobbe ITT AND STATE OF BIRTH /II noOM USA.. name country/ Omaha, Nebraska Na . AGE - Last Birthday (Yrs.) 54 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) ; February 13, 1947 5b. MOS. I DAYS Sc . HOURS MINS. OCIAL SECURTIY NUMBER 505 -60 -9319 8a. PLACE OF DEATH HOSPITAL ■ Inpatient OTHER ❑ Nursing Home : AGILITY - Name /P not institution, give sheet and number) 1817 West 11th Street ❑ ER Outpatient C Residence II DOA ❑ Other (Spealyr 71TY. TOWN OR LOCATION OF DEATH Grand Island 84. INSIDE CITY LIMITS Yes E4 No ❑ Be. COUNTY OF DEATH Hall County RESIDENCE - STATE Nebraska 9b. COUNTY Hall Sc . CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (including Zip Code) 1817 W. 11th St., 68803 1 9e INSIDE CITY LIMITS "4-64 No ❑ RACE - (e.g., White. Black. American Indian. e1c.1 (Speciy) White 11. ANCESTRY le.g.. Italian, Mexican. German, etcl ISpecityl American 12. x MARRIED ❑ WIDOWED NEVER DIVORCED ❑ MARRIED ❑ 13. NAME OF SPOUSE (It wde. give maiden name) Rich Stobbe USUAL OCCUPATION (Give kind of work done during most of working life, even if retired/ Registered Nurse 14b. KIND OF BUSINESS INDUSTRY Medical I5. EDUCATION (Specy only highest grade completed) Elementary or Secondary (0-12) - College 11 -4 Or 5 4 FATHER - NAME FIRST MIDDLE LAST (Dec.) Richard NMI Smith 17. MOTHER FIRST MIDDLE MAIDEN SURNAME (Dec.) Eleanore NMI Stevens r. S :c. :a. 10. 14a 16. ANLE, S: COOPER ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT Amended March 20, 2002 VITAL STATISTICS 01 14865 CERTIFICATE OF DEATH 18. WAS DECEASED EVER IN U.S. ARMED FORCES? (Yes, no or unk.) III yes. give war and dates 01 services) 19b I fUMANT MAC G ADDRESS �. EMBALMER - SIGNATURE & LICENSE NO 21a METHOD OF DISPOSITION 2 28 F ERUNAL HOME -NAME _ ?2b. FUNERAL HOME ADDRESS (STREET OR R.F.D. Na, CITY OR TOWN. STATE, ZIP) 3213 W. North Front Street._ Grand Island, Nebraska 68803 28. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (0). AND (c)l PAR E) ��\I �y � 1 CC J L �� -- . Rt+.1 DUE TO, OR AS A CONSEQUENCE OF 2 6a (C) PART II Accident Undetermined Suicide El Pending Homicide Investigation Kleine Funeral Home C Cremation (b) g9 DID T WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND _HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -ON FILE -WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS€ICS`SECTION;WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 2 0 2002 1817 West 11th Street, Grand Island Nebraska 68803 DUE TO OR AS A CONSEQUENCE OF (STREET OR R.F.D. NO 10 3 7 Burial 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Ten, - 19a. INFORMANT - NAME Rich Stobbe CITY OR TOWN. STATE. ZIP) Removal Donation 21b. DATE 201602544 21c. CEMETERY OR CREMATORY NAME Dec. 28, 2001 Grand Island City Cemetery 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Grand Island Nebraska Interval between onset anc aeali 'la Interval betwee onset and death Interval between onset anc' OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related 266 DATE OF INJURY (MO.. Day. Ye) 25e. INJURY AT WORK Yes ❑ No ❑ 270. DATE OF DEATH /Ma. Day Ye) 27b. DATE SIGNED (Mo.. Day. Yr) 21d. To 'be best of my knowled e. de occurr causes) stated. (Signature and Till �- 27cJ TIME OF DEATH a re time, date and place and due to the M OBACCO USE CONTRIBUTE T ❑ YES E F DEATH" I UNKNOWN PPRT III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? ( Ages 10 -54) Yes No 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED MI 264 PACE OF INJURY - At home, farm. street. factory oNtce building, etc. )S 0 26g. LOCATION 26 AUTOPSY Yes - 1 No IX STREET OR RF.D. NO 28a. DATE SIGNED (Mo.. Day. Ye 26c. PRONOUNCED DEAD (Mn . Day. Ye) 28b 28d. 2S_ WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER Yes I I No CITY OR TOWN STATE TIME OF DEATH M PRONOUNCED DEAD /Hour 28e. On the basis of examination and or Investigation, in my opinion death occurred at the time. date and place and due to the cause/s/ stat ed. r- (Signature and Title) • a HAS ORGAN OR TISSUE DONATION BEEN CO RED? 3tSb WAS CONSENT GRANTED? ❑ YES NO ❑ YES Grand Kimberly Nickels, M.D. 729 N Custer A Island, - ,_. ze . Ne raska 6 $0? 32a. REGISTRAR _ 2b DA &'•REGIS RLEt 'Ito, D44' Yr/ r, I , , JA IV 9 2x02 M