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A
<br />2. SEX 1 3. DATE OF DEATH /Month. Oar Yearl
<br />Alma Magdalena Jenneman
<br />Female April 5, 2000
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<br />c
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<br />UNDER 1 DAY
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<br />Lodge Pole, Nebraska
<br />YrsJ 88
<br />June 22, 1911
<br />7 SOCIAL SECURTIY NUMBER
<br />Z
<br />• 507 -62 -0111
<br />_
<br />Bb. FACILITY - Name /f/ not nstilution. give sheer and number)
<br />Tiffany Square Care Center
<br />z
<br />tv
<br />8d. INSIDE CITY LIMITS
<br />ee. COUNTY OF DEATH
<br />=
<br />D
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER llnduding Zp Ccx/ei 9e INSIDE CI f LIMITS
<br />Nebraska
<br />CD
<br />A Z
<br />3119 W. Faidley 68803 Yes ❑X No ❑
<br />10. RACE - (e.g.. White. Black American Indian.
<br />2
<br />N
<br />13 NAME OF SPOUSE /tf wife . give maiden name/
<br />etc.)(Speciyl
<br />white
<br />m
<br />-��
<br />'� o
<br />O �_
<br />0
<br />D
<br />(m'1
<br />Domestic
<br />Element or Secondary 10 12) College 11 - l or 5-
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />t7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Henry Doelling
<br />~
<br />�_ -r
<br />O
<br />Ye �f�°o o, unk.1 111 yes. give war and dales of services)
<br />` I r
<br />William Jenneman
<br />r19b INFORMANT MAILING ADDRESS (STREET OR R F D NO.. CITY OR TOWN. STATE. ZIP)
<br />21 West 12th St., Grand Island, NE. 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />//
<br />"l' / I t ,
<br />®Burial ❑ April 10, 200 Westlawn Memorial Park
<br />cm
<br />Removal I
<br />21 c CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME - NAME
<br />Apfel- Butler - Geddes
<br />❑ Cremation ❑ Donation Grand Island, Nebraska
<br />22D FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a) Ib). AND (c)) Interval between onset and dean
<br />PART
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<br />' (aI / / /j; 0 Dcif 5- - --
<br />rT? 4" ,.
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<br />28e. On the basis of examination and or Investigation, in my opinion death occurred at
<br />the time, date and due to the causelsl stated.
<br />a
<br />°
<br />°
<br />causes) stated. / I1
<br />1
<br />place and
<br />��
<br />��
<br />Si nature and Tnle ► _
<br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED'
<br />❑ YES gL NO ❑ UNKNOWN
<br />YES NO
<br />❑ YES W NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Dr. Thomas F. Werner, 244 W. Fai
<br />le Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />/.
<br />10906
<br />32b. DATE FILED BY REGISTRAR /A40. Day. Yr.)
<br />APR 12 20M
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<br />LOT 6, BLOCK 43, CHARLES WASNER'S SECOND ADDITION TO THE CITY OF GRAND ISLAND, HALL COUNTY,
<br />NEBRASKA.
<br />WHEN THIS COPYCARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT' CERTIFES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL REC0R ON-fi E-i TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STICSSE TI011. , - .:
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />AMWWOPOR 55
<br />200104566
<br />MAY 12000 ASSISrANr--SVWnrM9 -
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SIOW,9011
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES-FII��So�il`
<br />VITAL STATISTICS 7 _-
<br />CERTIFICATE OF DEATH = _
<br />S SG
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX 1 3. DATE OF DEATH /Month. Oar Yearl
<br />Alma Magdalena Jenneman
<br />Female April 5, 2000
<br />4. CITY AND STATE OF BIRTH lffnolrr U A_ name countryl
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />Sb. MOS I DAYS
<br />Sc HOURS MINS
<br />Lodge Pole, Nebraska
<br />YrsJ 88
<br />June 22, 1911
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />• 507 -62 -0111
<br />HOSPITAL ❑ Inpatient OTHER [X� Nursing Home
<br />,❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name /f/ not nstilution. give sheer and number)
<br />Tiffany Square Care Center
<br />❑ DOA ❑ Other /$pec,fv,
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />ee. COUNTY OF DEATH
<br />Grand Island
<br />Yea ® Np ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER llnduding Zp Ccx/ei 9e INSIDE CI f LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />3119 W. Faidley 68803 Yes ❑X No ❑
<br />10. RACE - (e.g.. White. Black American Indian.
<br />11. ANCESTRY leg.. Malian. Mexican, German, etc)
<br />12. ❑ MARRIED ® WIDOWED
<br />13 NAME OF SPOUSE /tf wife . give maiden name/
<br />etc.)(Speciyl
<br />white
<br />(Specdyl
<br />American
<br />NEVER DIVORCED
<br />MR
<br />Francis H. Jenneman
<br />_
<br />14a USUAL OCCUPATION IGrve kind ot work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Spec4y, only highest grade completed)
<br />of w kmg life. even Areliredl
<br />Homemaker
<br />Domestic
<br />Element or Secondary 10 12) College 11 - l or 5-
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />t7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Henry Doelling
<br />Emma Bolz
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />Ye �f�°o o, unk.1 111 yes. give war and dales of services)
<br />` I r
<br />William Jenneman
<br />r19b INFORMANT MAILING ADDRESS (STREET OR R F D NO.. CITY OR TOWN. STATE. ZIP)
<br />21 West 12th St., Grand Island, NE. 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21a. METHOD OF DISPOSITION 21b. DATE 21c CEb'ETER'Y OR CREMA70HV NAME
<br />"l' / I t ,
<br />®Burial ❑ April 10, 200 Westlawn Memorial Park
<br />'1. .- .f �•2�
<br />Removal I
<br />21 c CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME - NAME
<br />Apfel- Butler - Geddes
<br />❑ Cremation ❑ Donation Grand Island, Nebraska
<br />22D FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a) Ib). AND (c)) Interval between onset and dean
<br />PART
<br />1�
<br />' (aI / / /j; 0 Dcif 5- - --
<br />�U t I U" A, a "��,t�r�rv��
<br />Iht
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Interval between onset and oea!r
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />II
<br />(Ages 10 -54) Yes No
<br />Yes No X
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /Mo.. Day. YrI
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident R Undetermined
<br />M
<br />F] Suicide 1:1 Pending
<br />26e INJURY AT WORK
<br />261. PLACE OF INJURY - At home. farm. street lactory
<br />26g. LOCATION STREET OR R. F.0 NO. CI T OR TOWN S7 A T E
<br />Homicide Investigation
<br />yes No
<br />❑ ❑
<br />o Ice bmtdirtg, etc (5'Pacify)
<br />27a. DATE OF DEATH (Mo_ Day Yr.)
<br />28a. DATE SIGNED ;MO.. Day Yr I
<br />28b TIME OF DEATH
<br />April 5 2000
<br />05=
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<br />E a <
<br />27b DATE SIGNED fMO. Day Yr)
<br />27c. TIME OF DEATH
<br />29c. PRONOUNCED DEAD lMo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (HOUr1
<br />Aril 10 2000
<br />4:14 PM
<br />J
<br />¢ _ °
<br />M
<br />88.
<br />27d. To the best of my knowledge. q2ath occurr at the 6me. date antl place and due to the
<br />28e. On the basis of examination and or Investigation, in my opinion death occurred at
<br />the time, date and due to the causelsl stated.
<br />a
<br />°
<br />°
<br />causes) stated. / I1
<br />1
<br />place and
<br />ISI nature and Title ► I
<br />Si nature and Tnle ► _
<br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED'
<br />❑ YES gL NO ❑ UNKNOWN
<br />YES NO
<br />❑ YES W NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Dr. Thomas F. Werner, 244 W. Fai
<br />le Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />/.
<br />10906
<br />32b. DATE FILED BY REGISTRAR /A40. Day. Yr.)
<br />APR 12 20M
<br />
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