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c <br />Cn <br />x \ M N CT <br />O Lam. <br />C> "*t O =' <br />Z. <br />CO <br />r\3 00 <br />a <br />CU <br />ca <br />Legal: All of the Southerly 72' of Lot 9, Block 2, Boggs and Hill's Addition <br />City of Grand Island; Hall Clounty, Nebraska. <br />MIEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANSI HUMAN-SERWCES <br />SYSTEM RCERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORIG /NAL�'O4FIL _WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $TAT fION, 90PH&H IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS �J <br />DATE OF ISSUANCE <br />200104832 <br />�]]�� 00 22��0o El�g <br />LINCO EBRAS ASSISTANT ESTATE REGISThO <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMA14FR7�3C 9 ANEaUPPORT <br />VITAL STATISTICS - -_ <br />CERTIFICATF nF nF.A -eH - == <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />S DATE OF DEATH /Month Day Yearl <br />Ella Jane Casteel <br />Female` <br />04 -15 -2000 <br />4. CITY AND STATE OF BIRTH Onot inn USA.. name coumryl <br />Sa. AGE - Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16 . DATE OF BIRTH iMonth. Day Year) <br />MOS DAYS <br />SC HOURS' MINS <br />Wood River, Nebraska <br />(Yrsl 1 Sb <br />O <br />8 <br />July 27, 1718 <br />7. SOCIAL SECURTIY NUMBER <br />Be PLACE OF DEATH -- <br />506 -28 -7228 <br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name (d nor institution. give street and number) <br />Mary Lanning Memorial Hospital <br />❑ DOA ❑ Other,Specdv, <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8 I INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Hastings, Nebraska <br />Yes [X Nd ❑ <br />Adams <br />9a. RESIDENCE - STATE <br />91, COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER /Including Zip Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />404 Woodland Drive <br />Yes ® N. <br />10. RACE - (e.g., While. Black. Amedoan Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE !l/ wife. give maiden name) <br />etc.) (Specify) <br />White <br />(Specilyl <br />I American <br />NEVER DIVORCED <br />MARRIED <br />Kenneth Casteel <br />14a. USUAL OCCUPATION (Give kind of work done during most 141b <br />. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of wonting life. even if retired) <br />Elementary or Becontlary 10.121 College n 4 or S <br />Laborer <br />Plastics Factor <br />OO <br />16. FATHER -NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Zilmer Burmood <br />Edith Harper <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />_ <br />19a INFORMANT - NAME <br />(Yes. no or unk I 111 yes. give war and dates of services) <br />NO <br />Bill Clark <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />Rt 2, Box 123 Loup City, Nebraska 68853 <br />20 ATURE6 CENSE NO. Uanav <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />MSQ <br />® Burial ❑ Removal <br />April 19/ 20 Wastlawn <br />Mffroric-d Park <br />22a. UN AL HOME - NAM <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />p, ,F T er GeCt , S IM <br />• ❑ Cremation ❑ Donation <br />Grand <br />22b. FUNERAL HOME ADDRESS (STREET OR R F.D. NO.. CITY OR TOWN. STATE, ZIP( <br />1123 West Second Street, Grand Island, Nebrask 8801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR sal. IN. AND (c)) i Interval between onset and Deal <br />PART <br />(a) <br />DUE TO, OR AS A CONSF#UENCE OF Interval between onset and dean <br />//-- <br />DUE TO. Or APIA CONSEQUENCE OF Interval between onset and cleatr <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />111 IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />25. WAS CASE REFERRED 70 MEDICAL. <br />PREGNANCY <br />II \ ��� <br />IN THE PAST 3 MONTHS <br />EXAMIN ER OR CORONER <br />(Ages <br />10 -54) Yes No <br />Vas No <br />Yes No <br />26a. <br />26b. DATE OF INJURY /MO.. Da, Yr./ <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident ❑ Undetermmed <br />/ <br />M <br />F] Suicide n Pending <br />26e, INJURY AT WORK <br />261 PLACE QF, INJURY - At home, farm street factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes No ❑ <br />otlice bmldng, etc fSpeciy) <br />27a. OF DEATH (MO. Day. Yr.) <br />28a DATE SIGNED (Mo.. Day Yrl <br />28b TIME OF DEATH <br />//DATE <br />T <br />M_ <br />3 N Q <br />27b. DATE SIGNED (Mb. Day Yr) <br />27c. TIME OF DEATH <br />28c PRONOUNCED DEAD (Mo.. Day, YU <br />28d. PRONOUNCED DEAD (Hours <br />a i <br />nn <br />a <br />z <br />M <br />M <br />27d. o the best W my knowledge, death occurred at the time, date and place and due to the <br />2Be. On the basis of examination and or investigation, in my opinion death occurred at <br />° ° <br />~ <br />causelsl stated. <br />a <br />the time. date and place and clue to the cause(s) stated. <br />�' <br />(Signature and Title 1, "\ v. '^ <br />(S, nature a. Title ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS OR AN OR TISSUE DONATION BBEEE'(N CONSIDERED' 30.b <br />WAS CONSENT GRANTED? <br />❑ YES NO ❑ UNKNOWN <br />❑ YES Vll NO <br />-)j <br />YES El NO <br />31, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Pr!lly-- <br />�!A f D 4 .1 U'( F CLAL 4VG. l�earg2 4, P Le <br />3ta REGISTRAR <br />32b. DATE FILED BY REGISTRAR /Mo. Day r. <br />AAAY -O M <br />