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<br />WHEN THVS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYS7FA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />v
<br />WE OF ISSUANCE r
<br />APR 14 2000 21 000049.0 99
<br />LINCOLN, NEBRASKA ASSIi,
<br />HEALTH AND H �j
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYIC-E$$(AA -$ T
<br />VITAL STATISTICS =R
<br />CERTIFICATE OF DEATH
<br />MIDDLE LAST
<br />2 SEX >3. DATEOF DEATH %MOnlh Day Year,
<br />Berta C
<br />Franklin
<br />Female' April 7, 2000
<br />4. CITY AND STATE OF BIRTH /M not in USA.. name counlryJ
<br />5a. AGE -Last Birthday
<br />DER t DA V 6 DATE OF BIRTH (MOnIA. Day Vear,
<br />Somerville, Massachusetts
<br />�ERI
<br />Vrs6n S�UN
<br />OU RS MINE;
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />77
<br />August 11, 1930
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />- --
<br />015 -24 -1476
<br />HOSPITAL ® Inpatient
<br />OTHER Nursing Home
<br />8b FACILITY - Name /Nnot,nslituaon, give 3bee1 and number) ❑ ER Outpatient ❑ Residence
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other ISpec,/w _
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH -
<br />Grand Island
<br />'vYr, o
<br />i <
<br />Yes ❑ No ❑
<br />27c TIME OF DEATH
<br />Hall
<br />9a RESIDENCE - STATE 9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Inclucng Z,p Code) 9e INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />1910 N. Howard 68803 Yes No ❑
<br />10. RACE - leg., White. Black. American Indian 11, ANCESTRY le.g.. Italian,
<br />etc) Specify)
<br />Mexican. German, elcl 12. © MARRIED
<br />❑ WIDOWED 13. NAME OF SPOUSE (I/ wile . give maiden name/
<br />ISpeafy)
<br />White En
<br />llsh NEVER
<br />MARRIED
<br />DIVORCED Wayne Franklin
<br />14a. USUAL OCCUPATION /Give kind o/ work done during most 14b. KIND OF BUSINESS INDUSTRY
<br />d working life, even i/ reeredl
<br />if
<br />15. EDUC ATION (Specify only highest grade completed)
<br />Food
<br />Grand Island Schools
<br />Elementary or S11ary (0 -12) College n 4 or 5 -i
<br />ILL
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST t 7. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />William Canterbury
<br />Louise Munn
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />- - - --
<br />(yes o. or unk.( (Il yes. give war and dates of serviced
<br />nu
<br />No
<br />Wayne Franklin
<br />you inrvnrnnn I MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( -- - - - --
<br />1910 N. Howard, Grand Island, NE. 68803
<br />20. EM1L LMa"E�R(- SIGNATURE B LICENSEE NO 21 a. METHOD OF DISPOSITION 21b. DATE �2�o CEMETERYORCREMATORY NAME
<br />`�--' Z- C�`L - {" ❑Burial E] Removal April 11, 2000 Central Nebraska Cremation
<br />22a. FUNERAL ME - NAME ltd CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes ®Cremalgn ❑ Donalbn Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) --
<br />1123 West Second, Grand Island, NE. 68801
<br />23 IMMEDIATE 1,CAUtit J ��/[J/EN,TTER'0/N�L/Yy0 CAUSE PER LINE'F ^OR/la'1- ).�A/NND-(cll I �Wcf en onset and near,
<br />PART II\ /1 -e +_ _ -`wG T� C/r' "'� C� ✓ (WY
<br />'
<br />(at YV\ -lam i _ 1
<br />DUE TO, OR AS A CONSEQUENCE OF I Inter between onset and death
<br />_ (b) L�
<br />DUE 10. OR AS A CONSEQUENCE QF --
<br />Interval between onset and dean
<br />I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART ill IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />It PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER'
<br />26a. 26b DATE OF INJURY 1W.., Day. I,r, 26c. HOUR OF INJURY
<br />(Ages 10 -54( Yes No Ves No Yes No
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />11 Accident F1 Undelermined 1 _
<br />7 M
<br />Suicide F] Pending
<br />❑❑
<br />26e INJURY AT WORK
<br />261. PLACE OF INJURY - At home. la m. street. factory
<br />o ice building. etc. /Speciyl
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide InveSiigation
<br />Yes NO
<br />❑
<br />27a. DATE OF DEATH /Mp. Day Vc)
<br />28a. DATE SIGNED /MO.. Day Yrl
<br />28b TIME OF DEATH
<br />b <
<br />4
<br />y
<br />'vYr, o
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<br />276. DATE SIGNED /MO. Day vrl
<br />27c TIME OF DEATH
<br />28c. PRONOUNCED DEAD /MO.. Day, Yr.)
<br />M
<br />28d. PRONOUNCED DEAD /Noun
<br />g
<br />it 6U
<br />�D °,.5o P M
<br />��
<br />g £ °
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<br />27d. To the hest of my knowletlge. death occurred the time. d e and lace and due to the
<br />p
<br />M
<br />28e. On the basis of examination ,o, investigation,
<br />causeld stated.
<br />o
<br />and in my opinion death occurred at
<br />the time, date and place and due to the causes) stated.
<br />(SI nature and Title
<br />(Signal Title
<br />29. DID TOBACCO USE CONTRIBUTE TO HE DE H?
<br />ure and
<br />.a ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO UUNKNOW
<br />❑ YES O NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN
<br />nu
<br />Dr. Sitki Copur, 2116 W. Faidl
<br />Ave., Grand Island, NE. 68803
<br />(LO,06, 32b. DATE FILED BY REGISTRAR /MO.. Day, yr)
<br />APR 13 2000
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