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M n C) <br />-n <br />c D <br />M (In <br />[i C1 Z = o C7 Cn <br />= n v o o --a <br />N � > � :r <br />..,\ M __j <br />J ©V N o Z <br />r o x rn <br />m te <br />r^ � <br />C::0 f D <br />J \ ( CD 7� <br />-.1 Cn <br />Cn <br />RE: Lot Six (6), Block One (1), Parkhill Subdivision in the <br />City of Grand Island, Hall County, Nebraska. <br />200002538 <br />WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN. SERVICES <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGMD_CkAf&WH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC `SECTION,- N0WdH4S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />APR 2 4 2000 <br />_ -- <br />ass/sTT sTxsTE�STIrr <br />LINCOLN, NEBRASKA HEALTH AND Hta4AN_SERVIC9s:Sy19TEfiU_ <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SMMC&i4* %7D 3[l ORr <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH — <br />O .�rn i- <br />N <br />O CL <br />O Cn <br />Cn <br />C:) = <br />O <br />W <br />C11 CD <br />W '-r <br />Z <br />Cb 9 <br />iI DECEDENT -NAME FIRST MIDDLE LAST <br />? SEX <br />3. DATE OF DEATH /Moron Day. Yearl <br />Lyle Everett Woods <br />Male • <br />I Aril 8 2000 <br />4. CITY AND STATE OF BIRTH tlf not In USA.. name country/ <br />Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAV <br />6. DATE OF BIRTH lMowl Day. Year) <br />Fullerton, Nebraska <br />7GE,- <br />77 6b <br />MOS DAYS <br />6c HOURS MIN$ <br />��L1 <br />March 1 1923 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />409 30 0150 <br />HOSPITAL ® locatiern OTHER ❑ Nursing Home <br />Fl ER Outpatient ❑ Residence <br />8b FACILITY - Name /a not institution. give street and numbed <br />St. Francis Medical Center <br />❑ DOA ❑ Other t$pec,to <br />8c. CITY TOWN OR LOCATION OF DEATH <br />8d INSIDE CITY LIMITS <br />I Be. COUNTY OF DEATH <br />Grand Island <br />Yee [I Nd "❑ <br />Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2515 W. Louise, 68803 <br />Yea U No ❑ <br />10. RACE - is g.. White. Black. American Indian <br />11. ANCESTRY (e. g.. Italian. Mexican, German, etc) <br />t 2. � MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE //t carte, give maiden name) <br />etc.)ISoec-tyl White <br />ISpecitO T. erican <br />t]t 1114b <br />ME=ER DIVORCED <br />Norm Jean McMullen <br />14a USUAL OCCUPATION /Give kind of work done during most <br />KIND OF BUSINESS INDUSTRY <br />1 S. EDUCATION )Specify only highest grade completed) <br />Elementary or Secondary 10 -t 21 College 11 4 or 5 -1 <br />of working life, even it retired) <br />Machinist <br />16 FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />�17 <br />Volentine NMI <br />Matilda NMI mcrl nn Id <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME <br />(Yes. no. or unk.l III yes. grve war aril dates of services) WWII <br />Norma Jean Woods <br />Yes <br />19b INFORMANT A I DDRES (STREET OR R.F.D NO., CITY OR TOWN. STAT= ZIP) <br />EMBt�MER - SIGNATURE &L N0. <br />21 a. POSITIO <br />1 AtE 21c. <br />CEMETERY OR CREMATORY NAME <br />iG3 <br />r22a <br />R.Bunal ❑ Removal <br />I Apr. 11 , 2000 Westlawn <br />Memorial Park Cem( <br />. UNERAL HOME ,NAM <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Kleine Funeral Home <br />❑ Cremation ❑ Donatan <br />Grand Island Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR RED NO CITY OR TOWN. STATE. ZIP) <br />3213 W. North Front St. , Grand Island Nebraska 68803 <br />2 IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND (cll Interval between onset and death <br />ART Pvl VS <br />la) /G L' r C'I%G <br />DUE TO, OR AS A CONSEOUENCE OF Interval between onsilif and death <br />i <br />Ibl I <br />_ _ _ <br />DUE TO. OR AS A CONSEQUENCE OF - imerval berecen orse! and dean <br />1 <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />AUTOPSY <br />25 AS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />11 <br />IN THE PAST 3 MONTHS? <br />MINER OR CORONER' <br />(Ages <br />10 -64) Yes No <br />Yes No <br />Yes D No <br />26a <br />26b DATE OF INJURY (Mo. Day Yr.l <br />26c HOUR OF INJURY <br />26tl. DESCRIBE HOW INJURY OCCURRED <br />Acadent F-1 Undetermined <br />M <br />El Suicide F-] Pending <br />26e INJURY AT WORK <br />261. PLACE INJURY - At home. farm, street. factory <br />26g. LOCATION STREET OR R F D NO. CITY OR TOWN STATE <br />HOmiCltle investigation <br />❑❑ <br />Yea No ❑ <br />,2F <br />office building, etc /Specify) <br />�. <br />27i DATE OF DEATH / Day. Yr.) <br />28a. DATE SIGNED IMO.. Day YO <br />28b TIME OF DEATH <br />} <br />$ 3i <br />° <br />27Ait DATE SIGNED / Day. rl <br />�c TIME OF DEATH <br />28c PRONOUNCED DEAD IMO. Day. Yrl <br />28d. PRONOUNCED DEAD (Hour) <br />° <br />:'place <br />° <br />2� To the best 0 my knowatig th occurred at the time, date and and due to the <br />28e. On the basis of examination and of investigation, in my opinion death occurred at <br />causels) staled. / <br />1`1 <br />the time. dale and place and due to the causelsl stated. <br />ISM nature and Title <br />Si nature and Total ► <br />2%�113 TOBAC W USE CONTRIBUTE TO THE DEATH' <br />HAS ORGAN OR TISSUE DONATION CONSIDERED' <br />WAS CONSEN❑TGR <br />ElNO U <br />BEEN <br />O <br />YD' <br />ES � NO <br />31 . NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print/ <br />Thomas F. Werner MD, 2444 W. Faidley, Grand Island Nebraska 68803 <br />32a. REGISTRAR <br />3b. DATE FILEAR STRR A; / <br />W.z_ r _ - <br />�l <br />Y , nnn <br />?t <br />