Laserfiche WebLink
WHEN THIS COPYCARWES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA"ERVICES <br />SYSTEM, R CERTIFIES TI# BELOW TO BE A TRUE COPY OF THE ORIGINAL RE WITH, <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT13MS M f *t MKi1S , <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE F! <br />MAR 2 0 2001 200103631 <br />ASSbgT�NT,4T <br />LINCOLN, NEBRASKA HEALTH AND 1k fi." 1 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERI liCFS F i Z -7SI ? SjOORT <br />VITAL STATISTICS 0 1 02498 <br />CERTIFICATE OF DEATH` <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX - 1 <br />3. DATE OF DEATr /Hoorn. Day. Yead <br />"}everly L. Beer <br />Female <br />March 5, 2001 <br />4. CITY AND STATE OF BIRTH t1l oof on USA.. name country) <br />5a. AGE - Las/ Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Moots. Day. Year/ <br />I DAYS <br />Sc.HOURS' MINS <br />Pender, r <br />(Y's Sb.MOS <br />V 7 <br />April 13, 1931 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />508 -32 -6853 <br />HOSPITAL: ❑Kinpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />Bb. FACILITY - Name /Bnol institution, give street and numW <br />_L' -I' <br />- ❑ DOA ❑ Omer (Spec,tvl <br />BTC. L ATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />qC.,y. <br />T,T nco n <br />Yes ® ❑ <br />Lancaster <br />No <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 />1512 Post Place <br />® ❑ <br />Yes No <br />10. RACE - (e.g.. White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, elcl <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /ff wde. give maiden name) <br />j�fu%,yl <br />(Specify) American <br />DIVORCED <br />=,, <br />Charles Beer <br />14a. USUAL OCCUPATION /Give kind of work done during most 14b <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of working /Ae. own if reared/ <br />Public Schools <br />Elementary or Secondary (0 121 dollege 11 -a or 5.1 <br />lZ <br />16. FATHER -NAME­ FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Georae Clalisen <br />Blance Griffen <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(ves. no. or unk.) Ilf yes, give war and dates of services) <br />No <br />Bequeathal Forms <br />19b INFORMANT MAILING ADDRESS (STREET OR R F 0 NO.. CITY OR TOWN. STATE. ZIP) <br />20. EMBALMER -SIG TUR LICENSEN <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY NAME <br />� <br />J/(, <br />-; V <br />❑ Bunal ❑ Removal <br />3 -5 -01 <br />Nebraska Anatomical Bd <br />122a. ftNERAL HOME ANAME <br />21(d, CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Neb . Anat • Bd • <br />❑ Cremation ® Donation <br />(11TI la IF NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />986395 Nebraska Medical Center, Omaha 68198 <br />21 IMMEDIATE CAU i� QAUSArPER LINE FOR lal Ibl. AND Icll Interval between onset ana oeatn <br />ONE <br />PART A <br />-NLY <br />I < C <br />(al <br />DUE TO, OR AS A CONSEOU CE OF Interval between onset and dear <br />(b) <br />DUE TO. OR AS lyCONSEOUENCE OF Interval between onset ana dear <br />OTHER SIGNIFICANT WNDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />11 <br />IN THE PAST 3 MONTHS? <br />E %AMiNER OR CORONER' <br />(Ages <br />10-54) Yes D No 0 1 <br />Yes No <br />Yes No <br />26a. <br />26b. DATE OF INJURY /Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />28d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Suicide Pending <br />28e. INJURY AT WORK <br />26f. W6 e E 1 F, INJ V ;A_ t homC, /arm. street factory <br />W6 bu SO'ecM'/ <br />28g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED (W. Day. Yr) <br />28b TIME OF DEATH <br />27b DATE SIGNS (M oiDay. Yc/ <br />3 <br />27c. TIME OF D <br />&. <br />2 PRONOUNCED DEAD IMO.. Day, Yr.) <br />28d, PRONOUNCED DEAD /Hour) <br />`�y' g <br />' ` <br />U`l 9 M <br />M <br />B <br />8 <br />27d. To the best of my knowledge ath occurr t the time, date and dace and due to its <br />28e. On the basis of examination and /or investigation, in my opinion death occurred at <br />�°. <br />causelsl staled. <br />v ZS <br />the time, date and place and due to the cause(sl stated. <br />(Signature and Title <br />Si nature and Title <br />29. DID TOBACCO USE CONTRIBUT100,11E DEATH? <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED'/ <br />F1 YES F1 NO NKNOWN 7a <br />1:1 YES ® NO <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (P YSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) <br />Edwarjd Rains .D., 1500 So. 48th St., 4800, Lincoln, NE 68506 <br />;1 32a. REGISTRA <br />32b. DATE FILED BY_REGISTrI Imp �O,ayOy <br />1 <br />`/I - <br />MAR 11• 0 <br />u <br />