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WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTE14 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/NA WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAF1Sf ', -WHICH H THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ - - DATE OF ISSUANCE - F EB 2 1 200103153 `- R 200 LINCOLN, NEBRASKA HEALTH A STA - TE OF NEBRASKA- DEPARTMENT OF HEALTH AND AiV"(jK`ORT VITAL STATISTICS (l, f1 O I�f CERTIFICATE OF DE TH ' -� 1 DECEDENT -NAME - A. CITY AND STATE OF BIRTH F Meadow rev 7 SOCIAL SECURTIY NUMBER 507 -10 -4118 not en U S A.. name country) seeetand Grand Island 9a. RESIDENCE - STATE 9b COUNTY Nebraska Hall 10 RACE (e g., White. Black. American IMian. 11 ANCESTRY leg.. etc I ISceulyl ISpecrly) Whi e 14a USUAL OCCUPATION /Give kind of wont done during most Of working life. even If refired) Teacher 16 FATHER- NAME FIRST MIDDLE Frank NMI _ 18 WAS DECEASED EVER IN U.S. ARMED FORCES? IYes no or unk.I I 18 yes. give war and Bates of services) LAST 2. _��♦3. DATE OF DEATH /Month Day. Year) - - Ter Male January 30 2001 5a. AGE - Last Birthday UNDER t YEAR UNDER 1 DAY 6. DATE OF BIRTH tMommn. Day. Year/ (Yrs 5b. MOS. DAYS 51. HOURS MINS. October 31, 1910 8a. PLACE OF DEATH HOSPITAL. ❑ Inpatient OTHER a Nursing Home ❑ ER Outpatient Residence ❑ DOA _ . _ ❑ Other ISp-4) 8d INSIDE CITY LIMITS 8e COUNTY OF DEATH -- Yes No ❑ I Hall Sc CITY TOWN na I nreT n - - «r nrv�rvumttcer H /rncvUdmg Lp Code) 9e INSIDE CITY —LIMITS Grand Island 8 0 St Dr., 68803 Yes lnr No ❑ alian. Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /lt wde t4FL give maiden name) • ican NEVER DIVORCED MARRI ui��h111 )se I 4b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speoly only highest grade completed) 1 Elementary or Secondary l0 12) College 1 . t n. Education 4 Years =IN' MOTHER FIRST MIDDLE MAIDEN SURNAME ['er Anna NMI Kinne 19a FORMANT -NAME -- -. - -.. Marian PS RQse Terry OR R F 0 NO CITY OR TOWN. STATE ZI Cemetery STATE - - - -- Kielne Funeral Home I U Cremation U Donation I Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE ZIPI 3213 W. North Front Street Grand Island Nebraska 68803 IMMEDIATE�AUSE PART / r y%7 IEyT R ONLY ONE CAUSE PER LINE FOR IaI Ibl. AND Ic)1 �O, Interval oetween onset a o nnarr. lal l `_i ?� . L��j /�1 - ? iii J, GL� DUE TO. Qi AS A C }S�EOUENCE OF !�,• Ap ,' 1 O Interval between onset and dear, IbI L ' y7 /NI �..-- �� Interval between onset and dnatr. ILI OTHER SIGNIFICANT CONDITIONS - Conditions contributing to th Aeath but not related PART III IF FEMALE. WAS THERE A 2Y AUTOPSY 2� WAS CASE REFERRED TO MEDIC PART1 J j PREGNANCY IN THE PAST 3 MONTHS? .A, r E %AMINER OR CORONE 'W (Ages 10 -54l Yes Ll No D Yes D No Yes N 26a 26D, DATE OF INJURj . Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undelemllned M Suicide Pending 26e. INJURY AT WOLACE QF INJURY At home, farm. street. factory 26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN ❑❑ ffice bwWirig. at /Speci/y/ M STATE Homicide Investigation Yes No $75. DATE OF DEATH /MO. Day Yc/ 28a DATE SIGNED Mo.. Day Yrl / Y 280. TIME OF Qjg7k = Januar 30,2001 =� �r'MQ„"� (�220/� 2jb. DATE SIGNED /Afo.. Day. Yr./ Z c TIME OF DEATH 28c PRONOUNCED DEAD /Mo_ Day. Yc) 28d. PRONOUNCED DEAD V! IHoun g February,,-02 2001 12:04pnm M¢ Qb To the best of my knp'wledgd. death oc rred at the time, date and place and due to the g M cause(sl staled. 0 28e. On Me basis of examination and, or investigation, in my opinion death occurred at the time. date and place and due to the cause(s) stated. (Signature and Title) Po , ISr nature antl Title ► DID TOBACCO USE CON I HI UTE TO THE DEATH? 3Qa HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? 3� WAS CONSENT GRANTED? ❑ YES O ❑ UNKNOWN ❑ YES NO ❑ YES NO 3t NAME AND ADDRES F CE IFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY At I UHNEYI /Type a nno FEB 0 8 2001