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REPORTER'S D0 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIDAMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL *�WtW wTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST=Sk&W#6 W i IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE _ AY5 Ai1fCL9'aCDOPER 200004095 ASSISTANt sta k istlaAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM_ � - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER\tCES.FIWANC-£ AND SUPPORT VITAL STATISTICS = - CFRTTFTC ATF- OF DF-ATH Fl DECEDENT NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH (Month Dar. Yeas' ;a n n 5a AGE Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) 5b MOS DAYS Sc. HOURS MINS DFSC lt9E HOW IN,I' 1 OCCURRED IYrs November 2 1942 UNK Iowa -rnn 2 D 7 SOCIAL SECURTIY NUMBER Be PLACE OF DEATH _ HomiUde InveSiigapon HOSPITAL. ❑ Inpatient OTHER a Nursing Home 483 48 9388 ❑ ER Outpatient ❑ Residence 8b FACILITY Name (Ifnalrnstitution, give sheer and number/ � ❑ DOA ❑ Other(Speahr Skilled Care U 1 St. Francis Skilled Care Unit 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yea ❑XI No ❑ Hall Be . RESIDENCE - STATE 9b COUNTY Q S D Nebraska Hall Grand Island 2608 Lamar Ave., 68803 c� 'M 12. 51 MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /ll wde give maiden name) etc)ISoearyi American �7y� lte ISoeoNl VYll M VZ = C/ 14a USUAL OCCUPATION /Grve kindoy work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION )Specify only highest grade completed) Elementary or Secondary 1012) Co a I1 .4 0, 5•' 2 dears cn O M Child Protective Service 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 (Dec. ? Ore NMI Juncker Dec. 1 Mar. aurite NMT_ ROB O Qa ` �� ZM I, t N .-+ f- 21a METHOD OF DISPOSITION 121b DATE 21c CEMETERY OR CREMATORY NAME �, /�'3j Burai ❑ Rem°val � Apr. 26, 20001 Osborne Kansas Cemetery 1 211 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 2 a F ERAL HOME -NAME rn C 4� '{ 3213 W. North Front St., Grand Island Nebraska p cD T7l C__ {-� � YES S NO t o ►-' o p Q — Q) '' ca -7' z p m G m C ; ZC FTi cn 4' a m co rn- o x o co � Z D REPORTER'S D0 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIDAMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL *�WtW wTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST=Sk&W#6 W i IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE _ AY5 Ai1fCL9'aCDOPER 200004095 ASSISTANt sta k istlaAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM_ � - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER\tCES.FIWANC-£ AND SUPPORT VITAL STATISTICS = - CFRTTFTC ATF- OF DF-ATH Fl DECEDENT NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH (Month Dar. Yeas' Shirley Ann Rouse Female' Aril 21, 2000 _ d CITY AND STATE OF BIRTH 11f not io U S.A name country! 5a AGE Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) 5b MOS DAYS Sc. HOURS MINS DFSC lt9E HOW IN,I' 1 OCCURRED IYrs November 2 1942 UNK Iowa 57 Smode o - 0..�nq 26e INJURY AT WORK 7 SOCIAL SECURTIY NUMBER Be PLACE OF DEATH _ HomiUde InveSiigapon HOSPITAL. ❑ Inpatient OTHER a Nursing Home 483 48 9388 ❑ ER Outpatient ❑ Residence 8b FACILITY Name (Ifnalrnstitution, give sheer and number/ � ❑ DOA ❑ Other(Speahr Skilled Care U 1 St. Francis Skilled Care Unit 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yea ❑XI No ❑ Hall Be . RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER ll,0uding ZP Codel Be INSIDE CITY LIMITS Nebraska Hall Grand Island 2608 Lamar Ave., 68803 Yea [R No ❑ 10. RACE - leg. White. Black American Indian 11. ANCESTRY Is g.. Italian, Mexican. German. etc) 12. 51 MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /ll wde give maiden name) etc)ISoearyi American �7y� lte ISoeoNl VYll NEVER DIVORCED M Leslie W. Rouse Sr. 14a USUAL OCCUPATION /Grve kindoy work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION )Specify only highest grade completed) Elementary or Secondary 1012) Co a I1 .4 0, 5•' 2 dears of working We. even drenredl Case Worker" Child Protective Service 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 (Dec. ? Ore NMI Juncker Dec. 1 Mar. aurite NMT_ ROB O 18 WAS DECEASED EVER IN US ARMED FORCES' 9. INFORMANT -NAME IYes no a, unk I II yes give war and dates of services) 1 Leslie W Rouse, Sr. No N/A _ 19b. INFORMANT MAILING ADDRESS fSTRFET OR R F D NO CITY OR TOWN STATE. ZIP) 2608 Lamar Ave., Grand Island Nebraska 68803_ 20 E.M8A"M ER SIGN PURE 8 LICENSE NC 21a METHOD OF DISPOSITION 121b DATE 21c CEMETERY OR CREMATORY NAME �, /�'3j Burai ❑ Rem°val � Apr. 26, 20001 Osborne Kansas Cemetery 1 211 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 2 a F ERAL HOME -NAME Kleine Funeral Home ❑ fe' a'' °" ❑ °on "' °" Osborne, Kansas 22b FUNERAL HOME ADDRESS (STREET OR R .0 NO CITY OR TOWN STATE. ZIPI 3213 W. North Front St., Grand Island Nebraska 2�( IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER UNE FOR Ial Ibl. AND (c)I Interval between onset and de.aln 'PART u es v. I-a l re. la, I� I - DUE TO OR ASIA CONSEQUENCE OF Interval between onset and 0-In i On A, ,. CONSEr:UE ^iCE OF Inta-d" bole- onset anc ream OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PARP9tl IF FEMALE WAS THERE A Za!AUTDPSV 25< -EXA CASE REFERRED MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' R EXAMINER OR CORONER' D(Ages 10 541 Yes ❑ No Yes ❑ No Yes 1 Nom -i- 261, DATE OF INJUR lMo Day Yrl 26, :-TOUR OF INJUR6d. DFSC lt9E HOW IN,I' 1 OCCURRED 4CCden1 Lj indetenri�netl M _ Smode o - 0..�nq 26e INJURY AT WORK 261 PLACE OF INJURY - AI ho e. farm. street. factory 26q LOCATION STREET OR R.F.D NO m CITY OR TOW% STATF. _ HomiUde InveSiigapon ye No Y11 ❑ ❑ nolce building. et.: So IVl ) � 274 DATE OF DEATH IMO Day Yrl - T 28a DATE SIGNED (Mo Day. Yr) 2Bb TIME OF DEATH �-ZI -OCR - M `rte �ib DATE SIGNED lMo Day. Y, j7c TIME OF DEATH 28, ° RONOUNCED DEAD lMo Day YO 2Bd- PRONOUNCED DEAD !HO si �' a a o¢ S F M - To the bst of my knowlee at te tme ate Ola d due � g 28e On the basis of examination and or Invesugauon, in my opinion death occurred at rr ° causelsl stated. ° ' me ume. date and place and due to the causefs) stated. ISi nature and Title) 0, D Signature and Title) ji, - DID TOBACCO USE CONTRIBUTE THE DEATH'+ 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 3g.G WAS CONSENT GRANTED' t29 ❑ /ES NO ❑ NKNOWN ❑ YES y NC {-� � YES S NO 32b DATE FILED BY REGISTRAR /MO. Day. Yr/ n. O