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Please file this Death Certificate against the following described real estate: WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND MM I SERVICES' - -.. SYSTEM IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORE#E 17TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC 1®'iG s THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE JUN 16 1998 204e0500 S ASS14KW S I 'BElTRW LINCOLN, NEBRASKA HEALTH AND H SERVJWI¢ fAMV STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIFS hiAF]iSi7PPOIf VITAL STATISTICS — — -- CERTIFICATE OF DEATH 8 00865 I DECEDENT -NAME FIRST MIDDLE LAST 2 SEX - EATH rMonrn Day Year) Vada Gladys Mohr Female January 24, 1 1998 a CITY AND STATE OF BIRTH /a rlpf kt US.A.. name county) 5a. AGE -Last Birthday I UNDER 1 YEAR UNDER t DAY 16 . DATE OF BIRTH iMonfh. Day. Year/ Gordon, Nebraska Ivrsl 98 Sb Mos. DAYS sp Houas Mws January 26, 1899 7 SOCIAL SECURTIY NUMBER Ba PLACE OF DEATH 507 -36 -1252 HOSPITAL ❑ Inpatient OTHER ® Nursing Home LJ ❑ ER Outpatient ❑ Residence 81b . FACILITY - Name (If not institution, give street and number) Hamilton Manor ❑ DOA ❑ Other,Spec,ty 8c CITY. TOWN OR LOCATION OF DEATH Ed. INSIDE CITY LIMITS Be COUNTY OF DEATH - Aurora yes ® ❑ Hamilton No 27a. DATE OF DEATH (Mo.. Day Yi/ 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (including Zp Code) 9e INSIDE CITY LIMITS Nebraska Hamilton Aurora 1515 5th Street, 68818 IN ❑ ,= $ ego T ° a ' 27b. DATE SIGNED /MO.. Day Yrl 13 Yes - 10. - (e.g.. White. Black. American Indian. 11. ANCESTRY leg.. Italian. Mexican. German, etc) t 2. ❑ MARRIED ® WIDOWED 13 NAME OF SPOUSE (n wne giGe ma,deo name) eRAAC,IE VY�VI 'Am "erican NEVER DIVORCED Peter Mohr ° MARRIED 28e. On the basis of examination and'br investigation, in my opinion death occurred at 14a. USUAL OCCUPATION /Gree kind of work done dwirp most D, gf lvorkrng tile. qY� it retiradl J a- 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade compleledl _ Eleme Secondary to 12) Col n 5 LlcenseJ Practical Nurse Nursing Home Owner or -a or tai 16 FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME �17 Charles Henry Busic Emma May Strong 18 WAS DECEASED EVER IN US. ARMED FORCES? 19a. I NFORMANT-NAME Iles no. or Unk.) lit yes . gave war and dates of servicesl antl Title No No I Lois Obermeier 19b INFORMANT MAILING ADDRESS (STREET OR R D NO_ CITY OR TOWN. STATE ZIP) 319 Jennifer, Aurora, Nebraska 68818 20 LMER - SIGNA ENSE 21a METHOD OF DISPOSITION 121b. DATE 21c CEMETERY OR CREMATORY NAME r&( d ®Burial ❑ Removal 01/28/1998 Westlawn Memorial Park Cemeter, 22 UNERAL HOME'- NA 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes Funeral Home ❑ Cremation ❑ Donal- I Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ial. fbf AND (cll inlerval between onset er,o PART I Ia1 - � DUE TO. AS A CONSEOU CE OF Interval between onset and meal, r (L I � �T Ib) f it t In V t. \ V' 1 V 2 _3"WkAS _ UUt I U. UK Ab A 1,UNbtUUt NI.t ur' Interval between onset and dealr OTHER SIGNIFICANT CONDITION - Condtfillfis contributing to the death but not related P ART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. AS CASE REFERRED TO MEDICAL PART �j� PREGNANCY 11 IN THE PAST 3 MONTHS') EXAMINER OR CORONER' (Ages 10 -541 Yes D No R Vey 0 No Yes No -- 26a 26b. DATE OFINJURV (MO.. Day. Yri HOUR OFINJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined 126C LJ M ❑ Suicide El Pend 9 26e. INJURY AT WORK 26t. PLACE OF INJURY - At home farm. sleet. factory office building etc (Specifyi 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STA tF ElHomicide Invesbgahon Yes No ❑ ❑ 27a. DATE OF DEATH (Mo.. Day Yi/ 28a. DATE SIGNED (Mo. Day yr I 28b TIME OF DEATH CK M- ,= $ ego T ° a ' 27b. DATE SIGNED /MO.. Day Yrl 13 27c TIME OF DEATH 28c PRONOUNCED DEAD (Mo.. Day. Yr.) 28d, PRONOUNCED DEAD /Hourl 30 M i M ° 27tl. To the Des) of my knowledge death occurred at the time, dale and plate and due to Me 28e. On the basis of examination and'br investigation, in my opinion death occurred at a ° causelsl stated. - O a - the time. date and dace and due to the causelsf stated oifi(Signature IS nature and Title) ► antl Title No 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30 It WAS CONSENT GRANTED' ❑ YES ❑ NO UNKNOWN N-YES ❑ NO ❑ YES N1 NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prinll Dr. Mike Sullivan, 1408 5th Street, Auypjalf Nebraskjf 6 18 32a. REGISTRAR 32b DATE FILED BY REGISTRAR /Mo.. Day. Yr.) 2A�k • JAN 3 01998 u