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2 = Z
<br />N
<br />h
<br />QJ WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN�M
<br />SYSTE1K RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA T►.4TI¢`S _ _
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200004647,
<br />JAN 2 12000 ASSISFANTSrATERE
<br />LINCOLN, NEBRA OF NEBRASKA- DEPARTMENT OF HEALTEHAA AffiWMDAN HUMAN S+
<br />Amended January 21, 2000 MALSTAnsnCS _
<br />CERTIFICATE OF DEATH -_-
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<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX - '
<br />TE OF DEATH (Month. Day. Year)
<br />Iva viola Tesmer
<br />Female
<br />December 27, 1999
<br />o_-4
<br />0
<br />Q
<br />UNDER 1 DAY
<br />Z 3>
<br />N
<br />M
<br />C
<br />z
<br />rn
<br />O
<br />7. SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />506 -20 -3588
<br />HOSPITAL © Inpatient OTHER ❑ Nursing Home
<br />ER Outpatient ❑ Residence
<br />8b FACILITY - Name (dnol institution, give street and number)
<br />O
<br />C>
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />SIDENCE - STATE
<br />M
<br />9c. CITY. TOWN
<br />a LM
<br />O
<br />M
<br />3
<br />r
<br />618 E. 8th, 68801
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<br />r a
<br />s
<br />ca
<br />10. RACE - (e.g., White. Black. American Indian
<br />vi
<br />t 2. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE tlt woe give d name)
<br />ek.I(Speafyl
<br />White
<br />(Specify)
<br />American
<br />I
<br />NEVER DIVORCED
<br />Anton Tesmer
<br />MARRIED
<br />14a. USUAL OCCUPATION /Give kindol work darn doing most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />J�C
<br />" enema r
<br />Domestic
<br />Elementary or Secop ary (0 -12) College 11.4 or 5.1
<br />`��'
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />M
<br />7HER
<br />Ella Mae McIntosh
<br />QJ WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN�M
<br />SYSTE1K RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA T►.4TI¢`S _ _
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200004647,
<br />JAN 2 12000 ASSISFANTSrATERE
<br />LINCOLN, NEBRA OF NEBRASKA- DEPARTMENT OF HEALTEHAA AffiWMDAN HUMAN S+
<br />Amended January 21, 2000 MALSTAnsnCS _
<br />CERTIFICATE OF DEATH -_-
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<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX - '
<br />TE OF DEATH (Month. Day. Year)
<br />Iva viola Tesmer
<br />Female
<br />December 27, 1999
<br />4, CITY AND STATE OF BIRTH ,d novin U-SA. nerve country)
<br />5e. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mbr1M. Day. Year1, [� 18
<br />1 7
<br />MOS. DAYS
<br />Sc. HOURS' MtNS.
<br />Grand Island, Nebraska
<br />V .I 5b.
<br />�-8�-
<br />December 24,-9±3-
<br />7. SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />506 -20 -3588
<br />HOSPITAL © Inpatient OTHER ❑ Nursing Home
<br />ER Outpatient ❑ Residence
<br />8b FACILITY - Name (dnol institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other (Specify,
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />SIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN
<br />9d SRE,(:,jyUN1SE�, (ATgr
<br />#'j►YtrarfiR
<br />Nebraska
<br />Hall
<br />,41N..+P7...
<br />Grana Island
<br />618 E. 8th, 68801
<br />QX Norl
<br />Yes
<br />10. RACE - (e.g., White. Black. American Indian
<br />11. ANCESTRY (a g.. Italian. Mexican. German• etcl
<br />t 2. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE tlt woe give d name)
<br />ek.I(Speafyl
<br />White
<br />(Specify)
<br />American
<br />I
<br />NEVER DIVORCED
<br />Anton Tesmer
<br />MARRIED
<br />14a. USUAL OCCUPATION /Give kindol work darn doing most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />J�C
<br />" enema r
<br />Domestic
<br />Elementary or Secop ary (0 -12) College 11.4 or 5.1
<br />`��'
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Walter Amos Youngs
<br />7HER
<br />Ella Mae McIntosh
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT -NAME
<br />IV nloo o. or unk.) (If yes. give war and dates of services)
<br />� � Anton Tesmer
<br />' 19b INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIPI
<br />618 E. 8t , Grand Island, Nebraska 68801
<br />20. E MER SIGNATUR E NO. /�� /_•
<br />ir �'�7V
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />®&vial ❑Removal
<br />Dec. 31, 1999
<br />Westlawn Memorial Park
<br />-,74FU NERAL HOME - NAM
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑Dretn�n ❑Dwatton
<br />Grand Island, 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 />-
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR I.). Ib' AND (•-•; Interval between onset and death
<br />PART I
<br />(a) L/
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />/ �D
<br />(b) rfl ProsrIC o vas-,
<br />DUE TO.OR AS A CONSEQUENCE OF Interval between orft and death
<br />OTHER IIGNIFICANT CONDITIONS - Conditions contributing to the death but not related I PART
<br />IN IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WA° CASE-REFERRED TO MEDICAL
<br />PART �� PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONERS
<br />(Ages
<br />10 -54) Yes 0 No
<br />Yes No
<br />Ves No
<br />26a.
<br />2tib DATE OF INJURY /MO.. Day Yr)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />M
<br />Suicide r1 Pending
<br />26e. INJURY AT WORK
<br />26f. PLLApCE OF INJURY - At , farm. street. factory
<br />budding, /SpecMy
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide investigation
<br />Yes No
<br />❑ ❑
<br />Deice etc.
<br />27a. DATE OF DEATH /Mo.. Day. Yr.))
<br />28a. DATE SIGNED (Mo., Day Yr.I
<br />28b. TIME OF DEATH
<br />/y 9
<br />yd,
<br />`i
<br />27b. DATE SIGNED (MO.. Day. Yr.)
<br />27c, TIME OF TH
<br />28c. PRONOUNCED DEAD (Mo.. Day. Yr.)
<br />28d. PRONOUNCED DEAD (Four)
<br />-.� -1��?%
<br />, 3M
<br />0
<br />€�
<br />M
<br />a
<br />�
<br />27d. To the best ol my krtowletlg occurred at N1e time, oat a
<br />dace and due to Me
<br />28e. On the basis of examination antl,or investigatton, to my opinion death occurred at
<br />F
<br />� 6
<br />° S
<br />causelsl stated.
<br />the time. date and place and due to to eauselsl s1aMd.
<br />(Si nature and Title
<br />Signature and Tale
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEAT ?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED'
<br />YES ❑ NO UNKNOWN
<br />❑ YES NO
<br />❑ YES ❑ NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Phnil
<br />Larry L. Hansen M.D. 3,P16 W. Fai 1 Grand Island, NE 68803
<br />(W,
<br />32a. REGISTRAR
<br />31p. DATE FILED BY REGISTRAR /Ab. Day. Yr.)
<br />)ff*k / 64,k--
<br />JAN 3 2000
<br />ti-la- II I
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