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WHEN THIS COPYCAR1 S THE RAISED SEAL OF THE NEBRASKA HEALTH A _ J O_ ERVICES SYSTEM, IT CERT/FES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI K#Nfi/CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS Wwlu DATE OF ISSUANCE NOV 16 2000 200104398 A se . LINCOLN, NEBRASKA HEALTH'V�M STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAAf- NWLONAH ' AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH I DECEDENT -NAME FIRS' MIDDLE LAST 2 SEX - -- - 3 DATE OF DEATH /MOnfh Day Yead Harold Fredrick Sutter Male' Nov 12 2000 CITY AND STATE OF BIRTH df not ih U SA name country) Sa AGE - Last BiMday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH !Month. Day. Year) Liberty, Nebraska IYt'55 Sb. MOS. DAYS Sc.HOURS MINS Jun 24 1915 7 SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 506 -05 -9080 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home ® ER Outpatient ❑ Residence 8b FACILITY Name ftf not institution. give street and number) St. Francis Medical Center ❑ DOA ❑ other lSp —tvi 8c CITY TOWN OR LOCATION OF DEATH Rd. INSIDE CITY LIMITS I 8e. COUNTY OF DEATH Grand Island Yes ® No ❑' Hall 9a RESIDENCE - STATE 19b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER !Including Zip Codel 9e INSIDE CITY LIMITS Nebraska Hall Grand IS 2021 W. Louise 68803 ❑ Yes® No 10 RACE - leg. While. Black. American Indian 11 ANCESTRY le.g. Italian. Mexican. German. etc! 12 MARRIED ❑WIDOWED 13 NAME OF SPOUSE (If wde. give maiden name) etc I �s"` a " �nlhite ,Specs "American �J NEVER DIVORCED Norane Royer MARRIED 14a JSUAL OCCUPATION /Give kind of wor4 Clone during most 1 db. KIND OF BUSINESS INDUSTRY I S EDUCATION (Specify only highest grade completed) of working fife. even d retired) Owner- Operator Retail Dairy Sales Elementary or Secondary (0 12) Collene 11 .4 or 5-1 12th Grade 4 16 FATHER NAME FIRST MIDDLE LAST _ 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Charles Sutter Bessie Withers 18 WAS DECEASED EVER IN US ARMED FORCES? 19a. INFORMANT - NAME (yes , or vok 1 (II yes give war and dates of services! No Norane Sutter 19b INFORMANT MAILING ADDRESS ISTREET OR FLED NO_ CITY OR TOWN. STATE. ZIP) 12021 W. Louise Grand Island, Ne 68803 - 2 EMBALMER - SIGNATURE 8 LICENSE NO 21 a. METHOD OF DISPOSITION 21b DATE 21C CEMETERY OR CREMATORY NAME cexd� ta,,x c� X143 [jd Buna, ❑ Removal Nov. 16, 2000 rand Island City 22a FUNERAL HOME NAME 21ci CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann ❑Cremation ❑Donation Grand Island NE 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI 601 N. Webb Road, Grand Island, NE 68803 GS I ""UTAi t I,AUSE (EN I EH ONLY UNE GAUSS HEH LINE YUH Ial. 10). ANU,C)I X ART la, CardiODulmonary Arrest Interval oetvreen onset and death I TmknnT.m DUE TO, OR AS A CONSEQUENCE OF Ib. Interval between onset and death I DUE TO OR AS A CONSEQUENCE OF Ic Interval between Onset and deals I OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL PART II PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' (Ages 10 -54) Yes No Yes El No Yes K No 26a 26b DATE OF INJURY (Mo.. Day. Yr./ 26C. HOUR OF INJURY 21 DESCRIBE HOW INJURY OCCURRED Acodent F-] Undetermined M S-0e, F-] Pending 26e. INJURY AT WORK 26L PLLApCE OF INJURY - At hon1�. !arm. sbeel. lactory 26g. LOCATION STREET OR R D. NO. CITY OR TOWN STATE Homicide Investigation yes No ❑ ❑ office building etc. /Spaciry) 27a DATE OF DEATH /MO. Oay Yr.) I 28a DATE SIGNED /MO.. Day. Yr I 28b. TIME OF DEATH a November M 27D. DATE SIGNED (MO Day rn 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMO. Day. Yr) 28d. PRONOUNCED DEAD /HOUrI o� Woo T. % gF M -gz� ° 00. M a 27d To the best of my knowledge. death occurred at the time, date and place and due to the 28e. On the basis of e% in bon and or i e igsaexd in my Opinion death occurred at .ousels) stated. ° the time, date and la and dr ousels) led. (S� nature and Title) 10 (,the nature and Title 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH, 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b ____ C NSENT RANTED? ❑ YES ❑ NO © UNKNOWN ❑ YES �r NO YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type a Pontl 45erom E Janulewicz, Hall County P.ttornev, 117 E 1st Grand Tsland, NE 32a REGISTRAR &#& / I,,i 4W limi nrl,me- nre% 32b DATE FILED BY REGISTRAR (Mo.. Day Yr) ^to -11 1- 1% /r - _ 11 - — __._.._,...r.,u. UL, - 0 A� 1.Uw U Luuu Exhibit '