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Corrects Instrument No. 200005008. Please file this Death Certificate against <br />--the following described real estate: <br />IMIBN TMS COPY CARRIES T14E RAISED SEAL OF THE NEBRASKA HEALTH AND HdMAWSERV/CES- <br />SYSTEM RCERTFAES Tim BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD QN ILE 1MTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TISTIC.S _wNewS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS — <br />DATE OF ISSUANCE <br />Alp <br />cmLc <br />JUN 16 1998 2pp,�{�5008 Ass/ s turn w__ <br />LINCOLN, NEBRASKA HEALTH AND HVW#,SERVW"MV <br />STATE OF NEBRASKA- ARTMENT OF HEALTH AND HUMAN SERIES tDhkkCiAi+EhSiVPPO & f <br />VITAL STATISTICS <br />RE= RE,CORuIM 0 0 0 52 <br />CERTIFICATE OF DEATH � 8 00865 <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX - EATH tMOnth Day Year) <br />-January <br />Vada Gladys Mohr <br />Female 24, 1998 <br />a CITY AND STATE OF BIRTH /e not in USA name Cwhtryl <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />6 DATE OF BIRTH (Month. Day Year/ <br />Gordon, Nebraska <br />nrsl 98 <br />January 26, 1899 <br />SD MOS DAYS <br />SC. HOURS' MIN$ <br />7 SOCIAL SECURTIV NUMBER <br />Be PLACE OF DEATH <br />507 -36 -1252 <br />HOSPITAL Inpatient OTHER ® Nursing Home <br />ER Outpatient - Residence <br />Bb FACILITY . Name /11 not (nslitul/on, give street and number/ <br />Hamilton Manor . <br />F-1 DOA Other(Spenlr <br />.. _ <br />iiiiiiiii <br />Bc CITY. TOWN OR L A <br />L <br />...,...�. . -_.v.. .1-4-- .. . <br />Aurora <br />yes ® No ❑ <br />Hamilton <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />9e. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER fmciudrng Zip Code) 9e INSIDE CITY LIMITS <br />Nebraska <br />Hamittotr -- <br />Aurora <br />, <br />10 Black. A merican Inman <br />11. ANCESTRY leg.. Italian. Mexican. German, etc) � <br />l2. ❑MARRIED WIDOWED <br />13 NAME OF SPOUSE u! wne give maiden name) <br />�(eg., <br />Ism "�rican <br />NEVER DIVORCED <br />Peter Mohr <br />$F6 <br />27d. To the Des) of m knowledge death occurred at the time, dale and place and due to the <br />Y 9 <br />MARRI <br />-- <br />14a. USUAL OCCUPATION (Give kind M work done dyTing moll �, <br />a <br />t bb KIND OF BUSINESS INDUSTRY ,-� !� <br />' Jh'/'1 <br />15. EDUCATION (Specify only highest grade completed) _ <br />Elemey4j or Secondary 10 -121 Cdlim II -a or o <br />y!ff"kmg life. Y� Areliredl, J <br />Llcenseld Yractical Nurse <br />Nursing Home Owner <br />` v <br />16 FATHER - NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Charles Henry Busic <br />Emma May Strong - <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME <br />(Yes no or unk.) ( (11 yes ...ve war and dales d servicesl <br />(Yes. Lois Obermeier _. <br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D NO_ CITY OR TOWN STATE ZIP) <br />Jennifer, Aurora, Nebraska 68818 <br />SIGNA E51 CENSE <br />21a METHOD OF DISPOSITON <br />1 <br />21b. DATE 21c <br />CEMETERY OR CRFMAT01 °� NAME <br />d <br />t22UNEIALHOME <br />® Burial FI Removal <br />01/28/1998 <br />Westlawn Memorial Park Cemeter <br />21d CEMETERY OR CREMATORY LOCATION CITY JP TOWN STATE. <br />- NA <br />Apfel - Butler- Geddes Funeral Home <br />❑ Cremation ❑ Domino, <br />I Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F O. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Grand Island. Nebraska, 68801 - 5899 — <br />L _..-- -..... _.._ ..1., , ..,< <.,n ,.., — ...(., (..(1 Interval between onset aria ar.m. <br />23 IMMEDIATE CAUSE <br />PART <br />)a1 Cyr D <br />w�V1n(YV�GN <br />DUE TO. OR ASfA CONSEOU <br />CE OF <br />(b) Feet' tire, <br />DUE TO, OR AS A CONSEQUENCE OF <br />-e I 0 <br />t - A -_ -- <br />V-, V 2 <br />III <br />Inlerval between onset ano nh.1l' <br />i <br />OTHER SIGNIFICANT CONDIT ION $ Card s contributlng to the death but not related <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTH$? <br />24 AUTOPSY <br />25. AS CASE REFERRED :R MEDICAL <br />EXAMINER OR CORONER' <br />PART I% <br />II .I _ C i .� U fi` /.p ��� r <br />)Ages 10 -541 Yes No <br />Yes No <br />Vey <br />26a <br />26b. DATE OF INJURY (Mo. Day. Wit <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />AccidenTF-JUnd.temmmed <br />M <br />- <br />Suicide -1 Pending <br />26e. INJURY AT WORK <br />261. PLLAqCE OF INJURY - At home. farm. sneer. factory <br />omice budding. etc /Specify; <br />26g. LOCATION STREET OR R F D NO. <br />CITY DR TOWN STA TF <br />Homicide Inveshgatior <br />Yes No <br />❑ ❑ <br />27a. DATE OF DEATH (Mo.. Day Yr; <br />26a. DATE SIGNED (MO Day yr I <br />26b TIME OF DEATH <br />/ <br />IiA 27b. DATE SIGNED (MO.. Day Yr1 27c TIME OF DEATH <br />a > 28c PRONOUNCED DEAD IMO.. Day. YrI <br />28d. PRONOUNCED DEAD (Hour( <br />M <br />$F6 <br />27d. To the Des) of m knowledge death occurred at the time, dale and place and due to the <br />Y 9 <br />�z o <br />° 2Be. On the basis of examination an0�or investigation, in my opinion death occurred at <br />° a the time, date and place and due to the cause(sl stated. <br />causelsl stated. - <br />IS ignature and Title) No / <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR <br />Si nature and Tale ► <br />TISSUE DONATION BEEN CONSIDEREDn 30.6 WAS CONSENT GRANTED' <br />ElYES NO 1z UNKNOWN <br />5VES El NO <br />El YES NO <br />.11. NAMC AIVU NUVr,CJJ Vr i.cn � �r. .. v ........ .........- ........ �.� -.. _.. _ _ _... - <br />Dr. Mike Sullivan(, r� 1408 (. � 5th . Street., AuW.ra, Nebrask?►6 §418 <br />32b DATE FILED BY REGISTRAR (Mo.. Day. YO <br />JAN 3 01998 <br />