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1. DECEDENT - NAME FIRST MIDDLE LAST Sandra Rieko Monk 2. SEX. Female 3: DATE OF DEATH (Month. Day Year) September 8, 2003 4. CITY AND STATE OF BIRTH (If not in USA.. name country) 5a. AGE - Last Birthday (Yrs.) 51 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) December 5, 1951 Scottsbluff, Nebraska 5b. MOS. I DAYS 5c. HOURS' MINS 7. SOCIAL SECURTIY NUMBER 505 -76 -8461 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatien OTHER: ❑ Nursing Home � - -- Bb. FACILITY - Name (If not institution, give street and number) 3028 Brentwood Place ❑ ER Outpatient X ❑ DOA ❑ Residence Other (Spect/vt 8c. CITY, TOWN OR LOCATION OF DEATH ( Grand Island 18d. NSIDE CITY LIMITS Be 1. COUNTY OF DEATH Yes n No ) Hall 9a. RESIDENCE - STATE Nebraska 9b, COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island ad. STREET AND NUMBER (Including Zip Code) 68801 3028 Brentwood Place 9e. INSIDE CITY LIMITS Yes Na 10. RACE - (e.g., White. Black. American Indian. etc.) IScecily) Asian 11. ANCESTRY (e.g.. Italian. Mexican. German,.etc) (Specify) Japanese 12. r . MARRIED ❑ WIDOWED ❑ NEVER ❑ DIVORCED MARRIED 13. NAME OF SPOUSE (If ode. give maiden name) Jon Monk - 14a. USUAL OCCUPATION (Give kind of work done during most .1 of working life, even if retired) Physicians Assistant 1 4b. KIND OF BUSINESS INDUSTRY Medical 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -121 College 11 -4 or 5-I 12 8 16. FATHER - NAME FIRST MIDDLE LAST 1 Stanley Miwa 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Yeme Yokimizo . 18. WAS DECEASED (Yes. no. or unk.) No EVER IN U.S. ARMED FORCES? (If yes. give war and dates of services( 19a. INFORMANT - NAME Jon Monk 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 3028 Brentwood Place_, Grand Island Nebraska 68801 20. F-JGt MER - SIGN y U ' R � E 8 LIC NO. �p,�� �� i x/71 !/ 1 # 10 7 1 21a. METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation D "a"n" 21 b. DATE Septa nter ]2, 2003 21c. CEMETERY OR CREMATORY NAME Island Grand Isd City Cemetery 22a. FUNERAL HOME - NAME w All Faiths Funeral Home 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS )STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 2929 S. Locust St., Grand Island, Nebraska 68801 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE b), AND (c)) u CA kiO � C u x Interval between onset and death 9Nrf DUE TO, OR AS A CONSEQUENCE OF q /1 i'r,- Al Inte al between onset and death DUE TO, OR AS A CONSEQUENCE OF inn"( (c) Interval between onset and death OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART II N �Y PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 -54) Yes No 15Z1.. . 24 AUTOPSY Yes ❑ No 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER ? - Yes No X 26a. 1 . Accident . Undetermined II Suicide NI Pending ) II Homicide Investigation ) 26b. DATE OF INJURY (M0.. Day. Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e. INJURY AT WORK Yes No ❑ ❑ 26f. PLACE OF INJURY - At home, farm. street factory office building. etc. (Specify) 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE IIII►rY..Y. YWYIYr�YI _ To be Completed by Attending PHYSICIAN ONLY — J 27a. DATE OF DEATH (Mo.. Day. Yr.) September 8, 2003 To be Completed by CORONER S PHYSICIAN m COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day. Yr) 28b TIME OF DEATH M 27b. DATE SIGNED (Mo.. Day. Yr.) 9 10 27c. TIME OF DEATH - 2 :30 a. M 28c. PRONOUNCED DEAD (Mo.. Day, Ycl 28d. PRONOUNCED DEAD (Hour) M 27d. To the best of my knowledge. deal tcdurr a he ti ' -, d. - and place and due to the 0 . cause(s) stated. 0-14° I (Signature and Title) ► 1 28e. On the basis of examination and' or investigation, in my opinion death occurred at the lime, date and place and due to the causes stated. )Signature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ' M' NO ❑ UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES II NO 30.b WAS CONSENT GRANTED? ❑ YES a NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Print) Gary Settje M.D., 2116 . Faidley -, ye., Grand Island, NE 68803 320 REGISTRAR .. - �. ► $ r 'r' 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) SEP 1 5 2003 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 STATISTISSSECt1ON,WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 9/16/2003 LINCOLN, NEBRASKA STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAR SER VICES FHVANCE AI }SUPPORT VITAL STATISTICS ANLEY S COOPER ASSfTAN T STATEREGISTRA R HEALTH AND HUMAN SERVICES SYSTEM 201603138 CERTIFICATE OF DEATH 03 G 6