200004454 - Laserfiche WebLink

Browse

WHEN TIAS COPY CARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMMN SERVICES SYSTEM, IT CERTFE:S THE BELOW TO BE A TRUE COPY OF THE ORIGINAL - R! QW ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST _ bECTION-,Vffi dH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. jA DATE OF ISSUANCE 200004454 __MAY 12 2000 = AS9OANTk- - t*10I$ftR LINCOLN, NEBRASKA HEALTHAND*IMANSERVICiS'SYS71W STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN WVVES FWAKE-AI�SUPI VITAL STATISTICS CERTIFICATE OF DEATH - - - -- I DECEDENT NAME FIRST MIDDLE LAS' SE% I 3 DA iPOF DEATH A4 III ;I,I, rear. Charlene Joan Snyder Female April 25, 2000 4 CITY AND STATE OF BIRTH df oof+n USA name counfryl 5a AGE - Last Bldhday UNDER I YEAR UNDER I OAY 6 DATE BIRTH rMonth. Day Te O 5b PAOS DAYS Sc HOURS MINS Comstock, Nebraska !Yrs: 69 June 8, 1930 7 SOCIAL SECURTIY NUMBER Pa PLACE OF DEATH 505 -34 -4838 HOSPITAL ® Inpatient OTHER ❑ Nursnq Horse ❑ ❑ 8b. FACILITY Name It nof"'Nittron, qry street and nu at l ER Outpatient Residence St. Francis Medical Center ❑ DOA ❑ One, lSpe,I1 -- - - -- - - - -- CITY TOWN OR LOCATION OF DEATH - -_ — r__.___, —__ _ -- r, 8c i fftl IN ,IDE CIT : L;M'TS .: COUN (Y OF DEATH - Grand Island © ❑ Hall Yes No _ 9a. RESIDENCE - STATE 19b COUNTY Y. TOWN OR LOCATION 9d STREET AND NUMBER incrudmq Zip code,){ 9e NSIDF CIT'i 7TT Nebraska Hall Grand Island 1307 W. Haggle Ave. YesE 10 RACE Ie.g.. While Black American Indian 11. ANCESTRY le g. Italian. Mexican. German. etc ED ❑ WIDOWED 13 NAME OF SPOUSE dt wne grve mardeu name! yl etc; ISuecJy White ISPecd American � NEVER DIVORCED James E. Sn der__ D L] � y I � MARRIE __ __ _ 14a USUAL OCCUPATION IGrve k:ndot work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpec,ly only highest grade completedl olworkrn I,e.even Arehr 1 Elemen - g� Secondary IO -,21 C Ilege ^ riOmema e)r Domestic Y�` �_ L— _ - 16 FATHER - NAME FIRST MIDDLE LAST i 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Kenneth Myers Helen Cleveland L I!a115 IB WAS DECFASED EVER IN US AHMEU HJHCEb'! 19a INYUH.— —.1 IY'25 nn of w�kJ I !It Yes Qve .vdr and dales i)f ServKeS No � _ I James E. Snyder_ - 19b INFORMANT MAILING ADDRESS ISTREET OR R F D NO, CITY OR TOWN. STATE ZIPI ---,%1307 W. Hagge Ave., Grand Island, NE 68801 _ 20 EMB LMER -SIG NATUFlE 3 LICENSE NO Lj 21a METHOD OF DISPOSI1rX 2'b DATE 2' c CFMETE RY OR C.RFNIA CRY NAME �, '�'L >e( ( B „r;a! ❑ Re.n °.,a, !(April 28, 20001 Douglas Grove Cemetery ?2a FUNERAL OME -NAME � � �_ r21tl CEMETERY OR CREMATC R'! LOCATION CITY OR TOWN STATE LJ , I Apfel- Butler - Geddes ” "ma °° ❑ °° Comstock,_ Nebraska 22b FUNERAL HOME ADDRESS ISTREET OR R.F.D NO. CITY OR TOWN. STATE ZIP) 1123 West Second, Grand Island, NE. 68801 _ Al 23 IMMEDIATE CAU //�/ � (ENTER ONLY ONE CAUSE PER LINE FOR a. Ib. AND Icp ' Inter^(vJal hetw�ee/n� onset a��n 11 , /yn'/ PART IMMEDIATE V "L �l/�� _ lam. –lam -� t:. / �C/ —_ __— J �t-C.r `_. • ��- DUE TO, OR AS A CONSEQUENCE OF ! l 1 InteroOl between onset - nearr DUE TO, OR AS A CONSJOUENCE OF IJ Ime—LaIle tveen onset aro d•aIr (c) — OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE WAS THERE A 2� AUTOPSY 25 WAS CASE REFERRED 10 ME UICA. PART PREGNANCY IN THE PAST 3 MONTHS' — XAMINER OR CORONER' II (Ages 10 54) Yes ❑ No Yes ❑ No Yes N. 26a. 26b DACE OF INJURY IMO. Day. Yr./ 26C HOU — _ ! NJURY 260 DESCRIBE HOW INJURY OCCURRED J Accident Undetermined I M li Suicide F-1 Pending 26e INJURY AT WORK 26t. PLACE OF INJURY At home. farm. Street. factory 2fiq. LOCATION STREET JR R F 0. NO CITY OR TOWN ST/', f ( ❑ ❑ oX�ce hullding. etc At ) [g:o-,c,d. Investlgdlipn Vey No - -- -- -- - — – 270. DATE OF DEATH IMo Day vr) 280 DATE SIGNED lhfo Dav °� 286 TIME OF DEATH h 27b. DATE SIGNED lMO. O y Yr 127c TIME OF DEATH ° r 2BC PRONOUNCED DEAD Me. Day. vcI 28tl PRONO NCED DEAL' /Mnu' r > w z i J z o � _ M a 27d. T° the best of my knowledne death 9cc rretl at th mm . tlate a C Mace and due In he 28e. On the bas s of a am.nat or nno or nvesllgal on n my op+nron rlealr c. urred a cause)sl stated i' / the lime. date and place ano — to the caU5e151 Staled. TOBACCO USE CONTRIBUT e DEATH? 30.0 HA.S ORGAN OR TISSUE DONATION BEEN CONSIDERED' —; 30 n +vAS CONSENT GRANTED'+ ❑ YES ❑ NO UNKNOWN ❑ YES �NO ❑ YES lel�NO IE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER PHYSICIAN OR COUNTY ATTORNEY. :Type or P, at) Sitki M. Copur M.D. 2116 W. aidley, Grand Island, NE 68803 GISTRAR 325 DATE FILED BY REGISTRAR IMo. Day Y1: OOO tr/,.�,.._ MAY 2 Z