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1. DECEDENTS NAME (First, MkMIe, Last)
<br />Bette Lou Dreikosen
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Month, Day, Year L:
<br />October 13, 2001
<br />4. SOCIAL SECURITY NO.
<br />507 -40 -5743
<br />58. AGE - Last
<br />Bktldey (
<br />65
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Month, Day, Year)
<br />June 1 1936
<br />7. BIRTHPLACE (City and State or Foreign Country)
<br />Bayard Nebraska
<br />MONTHS
<br />DAYS
<br />HOURS
<br />MINUTES
<br />8. WAS DECEDENT EVER IN
<br />U.S. ARMED FORCES?
<br />Oyes DEM ❑Unk.
<br />9a. PLACE OF DEATH (Check Doty one; see instructions on other side)
<br />HOSPITAL: a Inpatient ❑ ER/Outpatient ❑ DOA
<br />OTHER: ❑ Nursing Home ❑ Residence ❑ Other (Specify)
<br />91. FACIUTY NAME (If not Ina6Wtion, give street and number)
<br />Kindred Hospital
<br />9c. CITY, TOWN, OR LOCATION OF DEATH
<br />Kansas City
<br />9d. COUNTY OF DEATH
<br />Jackson
<br />10. MARITAL STATUS - Married, Never
<br />Memed, Widowed, Droned, (Specify)
<br />Married
<br />11. SURVIVING SPOUSES NAME
<br />If wife, give are maiden name)
<br />W ayne Dreikosen
<br />128. DECEDENTS USUAL OCCUPATION (Give kind of
<br />wort[ done during most of working life. Do not use retired.)
<br />Business Owner
<br />12b. KIND OF BUSINESS OR INDUSTRY
<br />Arts & Crafts
<br />138. RESIDENCE - STATE
<br />Nebraska
<br />13b. COUNTY
<br />Hall
<br />13c. CITY, TOWN, OR LOCATION
<br />Grand Island
<br />130. ZIP CODE
<br />68801
<br />13e. STREET AND NUMBER
<br />921 So. Locust
<br />139. INSIDE CITY LIMITS
<br />im ve. 0 No 0
<br />13g. YEARS AT PRESENT ADDRESS
<br />under 5 0 5 - 9 0 10-19 0 20 or more
<br />14. WAS DECEDENT OF HISPANIC ORIGIN
<br />(Specify No or Yes - If yes, specify Cuban, Mexican, Puerto Rican, etc.)
<br />0
<br />No ❑ Yes Specify*
<br />15. RACE - American Indian, Black White, etc.
<br />(Specify)
<br />White
<br />16. DECEDENT'S EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary/Secondary (0 -12)
<br />12
<br />Cdlege (1 -4 or 5+)
<br />PART II. OMaaIynllican1 condhlons 00 19948ng to death but not resu6n i tthe muse given in Part I.
<br />C+1VPO/OGi'O bI / ��N `L y , y / �f ( .
<br />II'` �
<br />24. IF DECEASED WAS
<br />p FEMALE EGNANT N THE
<br />90 DAYS?
<br />1 2
<br />❑ Yes ❑ No - 0 Unk.
<br />25a. WAS AN AUTOPSY
<br />PERFORMED?
<br />1
<br />❑ Yes No
<br />25b. WERE AUTOPSY FINDINGS
<br />AILABLE PRIOR TO
<br />C O CAUSE OF
<br />DEATH?
<br />1 2
<br />❑ Yes ❑ No
<br />11
<br />26. MANNER OF DEATH
<br />Natural ❑ Pending
<br />Investigation
<br />LJ Accident
<br />❑ Suicide ❑ Could not be
<br />Determined
<br />❑ Homicide
<br />27a. DATE OF INJURY
<br />(Month, Day, Year)
<br />279. TIME OF
<br />INJURY
<br />M
<br />270. WAS INJURY ALCOHOL-
<br />RELATED? MN 6019,0 w
<br />QBCedent
<br />1 2
<br />❑ Yes ❑ No ❑ Unk.
<br />274. INJURY AT WORK? - -
<br />1 2
<br />❑ Yes ❑ No ❑ Unk.
<br />27e. DESCRIBE HOW INJURY OCCURRED
<br />27f. PLACE OF INJURY - At home, farm street, factory, office
<br />building, etc. (specify
<br />27g. LOCATION (Street and Number or Rural Route Number, City or Town, State)
<br />28a. (Specify)
<br />4 0 CERTIFYING PHYSICIAN
<br />❑ MEDICAL EXAMINERICORONER
<br />286. To the best of m ow , death occurred at the time, date and place and due to the cause(0) stated.
<br />(Signature an Pat, ■ �J
<br />/'w J/'
<br />28c. DATE SIGNED
<br />(Month, Day, Year)
<br />to/ 'I/V/
<br />28d. TIME OF DEATH
<br />4:20 a M
<br />OR CO ER) (Type o, Print)
<br />29s. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL � EEXAMINEER RO
<br />li t,/ %' -e4 J ®2/ Q )1r j
<br />291. MO. LICENSE NUMBER
<br />30. WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER?
<br />❑ Yes No
<br />IM
<br />31. NAME OF ATTENDING YSI AN IF OTHER THAN CERTIFIER
<br />t Gf
<br />(Type or Print)
<br />32. REGI . - S SIGNATURE
<br />� / f ,
<br />33.. E RECEIVED BY LOCAL REGISTRAR
<br />th % • ` al
<br />3.:
<br />m, O
<br />TYPE/PRINT
<br />IN
<br />PERMANENT
<br />BLACK INK.
<br />FOR
<br />INSTRUCTIONS
<br />SEE OTHER SIDE
<br />AND HANDBOOK
<br />SEE
<br />INSTRUCTIONS
<br />ON OTHER SIDE
<br />INFORMANT
<br />DISPOSITION
<br />CAUSE OF
<br />DEATH
<br />REGISTRATION DISTRICT NO.
<br />cam 17. FATHERS NAME (First, Middle. Last)
<br />Walter NMI Foreman
<br />19a. INFORMANT'S NAME (Type/Print)
<br />Sayne Dreikosen
<br />20a. BURIAL CREMATION,
<br />OTHER Specify)
<br />Burial
<br />21. SIGNATURE OF FUNERAL SERV CE LICENSEE OR
<br />PERSON ACTING AS SUCH
<br />20b. DATE OF DISPOSITION
<br />Month, Day, )bar
<br />Oct. 18, 2001
<br />DUE TO (OR AS A CONSEQUENCE OF):
<br />MISSOURI DEPARTMENT OF HEALTH
<br />CERTIFICATE OF DEATH
<br />REGISTRAR'S NUMBER
<br />19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, Slate, Zip Code)
<br />921 So. Locust Grand Island Neb. 68801
<br />20c. PLACE OF DISPOSITION (Name of cemetery, cremator, or
<br />other place)
<br />Mount Hope Cemetery
<br />226. NAME AND ADORE
<br />Grand Island Neb. 68803
<br />Kleine Funeral Home 3213 W. North Front St.
<br />23. PART I. Enter the diseases,
<br />injuries, or cplkat caused ` raters dying, such as caNiac or respiratory anent, shock, or heart failure.
<br />Usl only one cause on each line. ss
<br />IMMEDIATE CAUSE a. SS 9
<br />(Final disease or DUE TO (OR AS A CONSEQUENCE OF):
<br />condition resulting
<br />in death) b. 741y4JO Vteot Yii i&e,sh G.+; �"'�"• ✓r11%dL� G((IrI�01 %/
<br />Sequentially list DUE TO (OR AS A CONSEQUENCE OF):
<br />conditions, if any,
<br />leading to immediate
<br />cause. Enter
<br />UNDERLYING CAUSE
<br />(disease or injury that
<br />Sulfated events resulting
<br />in death) LAST
<br />18. MOTHERS NAME (First, Middle, Maiden Surname)
<br />Opal NMI Durham
<br />124 -
<br />204. LOCATION - City or Town, State
<br />Valentine Nebraska
<br />STATE FILE NUMBER
<br />22b. FUNERAL ESTABLISHMENT
<br />LICENSE NUMBER
<br />Approximate Interval Between
<br />Onset and Death
<br />
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