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1 DECEDENT - NAME FIRST MIDDLE LAST <br />Todd William Muirhead <br />2. SEX <br />Male <br />3 DATE OF DEATH !Month Day. Year) <br />March 15, 2001 <br />4 CITY AND STATE OF BIRTH III not in USA.. name country) <br />Grand Island, Nebraska <br />5a. AGE - Last Birthday <br />t ' 60 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year) <br />February 28, 1941 <br />Sb. MOS 1 DAYS <br />Sc. HOURS ' MINS <br />7. SOCIAL SECURTIY NUMBER <br />506 -42 -4704 <br />8a. PLACE OF DEATH <br />HOSPITAL -446 Inpatient OTHER X Nursing Horne <br />❑ ER Outpatient ❑ Residence <br />❑ DOA ❑ Onerlspacdyt <br />eb. FACILITY - Name Of not mst,tot,on. give street and number) <br />St. Francis Skilled Care Center <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d. INSIDE CITY LIMITS <br />Yes lEi No ❑ <br />8e. COUNTY OF DEATH <br />Hall <br />98 RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip Code) <br />1011 S. Eugene 68801 <br />9e. INSIDE CITY LIMITS <br />Yes ID No ❑ <br />10. RACE - (e.g, White. Black. American Indian. <br />etc.) (Specify) <br />White <br />11. ANCESTRY (e. g Italian. Mexican. German. etcI <br />(Specify) <br />American <br />12. MARRIED ❑ WIDOWED <br />(� NEVER <br />❑ MARRIED ❑ DIVORCED <br />13. NAME OF SPOUSE 01 wde. give maiden name) <br />Mary Steinbach <br />1 4a. USUAL OCCUPATION (Give kind of work done during mos! <br />of working file, even if retired) <br />Store Manager <br />14b KIND OF BUSINESS INDUSTRY <br />Retail Sales <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary 10 -121 College II - or 5.1 <br />12 <br />(Yes Yes unk.) ( <br />(If yes. give war and dates of services) M <br />Muirneaa <br />19b. INFORMANT MAILING ADDRESS 1 STREET OR R. F. D NO CITY OR TOWN. STATE. ZIP( <br />1011 S. Eugene Grand Island, NE 68801 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO 2 <br />21a METHOD OF DISPOSITION 2 <br />21b. DATE 2 <br />21c CEMETERY OR CREMATORY NAME Service <br />N <br />22a FUNERAL HOME - NAME 2 <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP( <br />601 N. Webb Rd. Grand Island, Nebraska 68803 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la( . 5). AND (c)) Interval between onse, and death <br />PART <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY IN THE PAST 3 MONTHS? I I I EXAMINER OR CORONER <br />(Ages 10 -54( Yes I No ❑ Yes No Yes No W <br />26a. 26b. DATE OF INJURY (Mo. Day. Yr.) 26c. HOUR OF INJURY 268 DESCRIBE HOW INJURY OCCURRED <br />11 Accident . Undetermined M <br />■ Suicide . Pending 26e. INJURY AT WORK 261. Pffice bLACE uilding OF INJUetcRY - A <br />t home. farm. street factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />■ Homicide Investigation Yes <br />❑ ❑ o. S <br />No <br />27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED (Mo. Day Yo) 286. TIME OF DEATH <br />3.1.5 -- ©I M <br />y 27b. DATE SIGNED (Mo. Day. Yr.) 27c. TIME OF DEATH E i ° 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour) <br />g )_r 1. 1 M �i � M <br />276 To the best of my knowledge. death occurred at the time, date and place and due to the ~ .2 2 8 28e. On the basis of examination and-or investigation. in my opinion death occurred at <br />' cause(s( stated. / / ° a the time, date and place and due to the cause(s) stated <br />(S,gnature and Title) Or V`^ - ` (Signature and Title( ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.0 HAS ORGAN OR TISSUE DONATION BEE CONSIDERED 30.2 WAS CONSENT GRANTED? ��-7� <br />❑ YES ❑ NO g UNKNOWN ❑ YES I XI NO ❑ YES 'I�� NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or PnrrlI( \�� `^C. <br />Dr. Anne K. Morse, M.D., 729 N. Custer, Grand Island, NE 68803 <br />fa <br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day. Yc) <br />��,�„ MAR 1 9 2001 <br />16. FATHER - NAME <br />4 Harry D. Muirhead <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES <br />1 <br />4 <br />(0( <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL_RECORQ ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$I - SEC.TIOI = WHICH IS <br />S <br />THE LEGAL DEPOSITORY FOR VITAL RECORD <br />DATE OF ISSUANCE <br />MAC 2 0 2009 Lis coOPER <br />ASSISTANT <br />LINCOLN, NEBRASKA HEALTHAND-HUMAN SERVICES SYSTEM -- <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS 01 02662 <br />FIRST <br />DUE TO. OR AS A CONSEQUENCE OF <br />IDDLE LAST <br />CERTIFICATE OF DEATH <br />r9a. INFORMANT - NAME <br />17 MOTHER <br />Olga <br />FIRST <br />MIDDLE <br />L. Giesenhagen <br />201702769 <br />MAIDEN SURNAME <br />Interval between onset and deatn <br />16. FATHER - NAME <br />4 Harry D. Muirhead <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES <br />1 <br />4 <br />(0( <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL_RECORQ ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$I - SEC.TIOI = WHICH IS <br />S <br />THE LEGAL DEPOSITORY FOR VITAL RECORD <br />DATE OF ISSUANCE <br />MAC 2 0 2009 Lis coOPER <br />ASSISTANT <br />LINCOLN, NEBRASKA HEALTHAND-HUMAN SERVICES SYSTEM -- <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS 01 02662 <br />FIRST <br />DUE TO. OR AS A CONSEQUENCE OF <br />IDDLE LAST <br />CERTIFICATE OF DEATH <br />r9a. INFORMANT - NAME <br />17 MOTHER <br />Olga <br />FIRST <br />MIDDLE <br />L. Giesenhagen <br />201702769 <br />MAIDEN SURNAME <br />Interval between onset and deatn <br />