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1. DECEDENT - NAME FIRST MIDDLE LAST John Christian Var Oosbree 2 SEX male 3 DATE OF DEATH /Month Day Year) December 5, 1999 4. CITY AND STATE OF BIRTH (If not in US. A.. name country) Sioux Center, Iowa 5a. AGE - Last Birthday (Yrs.) 73 UNDER I YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) May 11, 1926 5b. MOS. I DAYS 5c. HOURS MINS. •_ 7. SOCIAL SECURTIY NUMBER 483 -22 -3547 Ba. PLACE OF DEATH HOSPITAL x Inpatient OTHER: ❑ Nursing Home 9i, FACILITY - Name (If not Institution, give street and number) ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other ,Spec (y, St. Francis Medical Center 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS yes f, l No ❑ Be. COUNTY OF DEATH Hal]. 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 1901 W. 1st 68803 9e. INSIDE CITY LIMITS Yes x No ❑ 10. RACE - (e.g., White. Black. American Indian. etc.) lSpecdyl white 11. ANCESTRY leg.. Italian. Mexican, German, etcl (Specify( AmPri ran 12. © MARRIED ❑ WIDOWED NEVER (l DIVORCED ❑ MARRIED I I 13. NAME OF SPOUSE (If wde. give ma den name) Norma Goodmanson 14a. USUAL OCCUPATION (Give kind al work done during most I of working life, even if retired) telephone lineman 14b. KIND OF BUSINESS INDUSTRY communication 15. EDUCATION (Specdy only highest grade completed) Elementa or Secondary 10 -12) College 11 or 5.1 1 16. FATHER - NAME FIRST MIDDLE LAST e 1 John C. Van Oosbree 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Marie VanVelzen ■ 18. WAS DECEASED (Yes. no or unk.) I yes EVER IN U.S. ARMED FORCES? l (If yes. give war and dates of services) 110/30/44 to 10/31/48 19a INFORMANT - NAME 1 Norma Van Oosbree OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART , II ------C-1 r- , . - e PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 - 54) Yes r No ❑ 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER Yes ❑ No L Yes I No l' 26a. D Accident ■ Undetermined • Suicide II Pending 111 Homicide Investigation 265. DATE OF INJURY (Mo. Day. Y. 26c. HOUR OF INJURY M 264. DESCRIBE HOW INJURY OCCURRED 26e. INJURY AT WORK Yes ❑ No ❑ 261. P P1 A E OF. .At home . farm. street factory tl 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATH /Mo.. Day. Yr) December 5, 1999 To be Completed by CORONER PHYSICIAN. or COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo. Day Yr.) 285. TIME OF DEATH To be Completed Attending PHYSIC ONLY 27b. DATE SIGNED (Mo.. Day. Yr) I ` l `� 27c TIME OF DEATH 8 :04 A M 28c. PRONOUNCED DEAD (Mo.. Day. Yr/ 284. PRONOUNCED DEAD (Nowt M ( //5 274. To the st of my kfrowle e. d Ih occurred at time, ale and place and due to the causels) stated. (Signature and Title) O. 1' V V \ J 28e. On the basis of examination and -or investigation, in my Opinion death occurred at the time. date and place and due to the causels stated. ' (Signature and Title) Ilk 29. DID TOBACCO USE CONTRIBUTE T THE EATH? ❑ YES 1NO ❑ UNKNOWN 30.a 13AS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES EJ--6 30.b WAS CONSENT GRANTED? YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Pont) Kimberly A. Mickels M.D. 72 N. Custer, Grand Island, Ne 68801 32a. REGISTRAR 601940,a1". '325 DATE FILED BY REGISTRAR (Mo, Day. Yc) DE 9 7999 • 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 STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE ANLEY S. COOPER DEC 1 0 1999 ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE E O DEATH 195. INFORMANT MAILING ADDRESS 1901 West 1st Street, Grand Island, Nebraska 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO. not embalmed 22a. FUNERAL HOME . NAt'E Home Apfel - Butler- Geddes Funeral 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, Nebraska 68801 -5899 23. IMMEDIATE CAUSE PART I (b) DUE TO, OR AS A CONSEQUENCE OF i'UE TO. C. 4 AS A COIISEOUENCE OF. (STREET OR R.F. NO., CITY OR TOWN. STATE. ZIP) Cremation Donation (ENTER ONLY ONE CAUSE PER LINE FOR la( . lb). AND lc)) 21d. CEMETERY OR CREMATORY LOCATION 201607370 21a. METHOD OF DISPOSITION 215. DATE - T 21 7 p t i Y �C i Mf q q �1 E C�L1�L G11 LV�UL �1SC1 ❑ Burial ❑Removal Dec. 5, 1999 1 Cremation Service CITY OR TOWN STATE 719 Front St. Gibbon, Nebraska Interval between onset and deals I' -' 10al between onset and deals Interva' between onset ai,n deal,.