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V ' vo Q M -n r) ; x C) n n = a M G1 2 C) en CD CD a N jW O N CD Cf�i O G o ca Crn Cn o l� 000 0-5-75-F WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE—r R .ON FI EiWrH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS StCTION, WH16H IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,; a - - P. DATE OF ISSUANCE r 0 AlAIJARZLEYS.COOPER ASSISTANT` STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERI jICES SYS MT - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERiWFSI-F_ QUNCR A_ ND SUF06RT VITAL STATISTICS rPRTTFTC ATP. ()F T)FATH - - 1 DECEDENT -NAME FIRST MIDDLE LAST CZ) p --+ >11 Male C A 4. CITY AND STATE OF BIRTH Itf not in US.A.. name countryl 5a. AGE Last Blnhday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH IMMM, Day. Year/ r 5c. HOURS MINS (Vrsl 5b Sedro -Woole , Washin ton 73 September 1 1926 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH HOSPITAL Inpatient OTHER ❑ Nursing Home (T1 „� Z7 D Uj 8b. FACILITY - Name fff not mstifution, give street and number/ BryanLGH Medical Center East ❑ DOA ❑ Other /Specityi Sc CITY TOWN OR LOCATION OF DEATH 84 INSIDE CITY LIMITS Be. COUNTY OF DEATH cn F� N Cn x � 9b. COUNTY a 9d. STREET AND NUMBER /Inducting Zip Coom 9e INSIOE CITY LIMITS ►-• .... We Grand Island rn 10. RACE - (e. g.. White. Black. American Indian. CD CD a N jW O N CD Cf�i O G o ca Crn Cn o l� 000 0-5-75-F WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE—r R .ON FI EiWrH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS StCTION, WH16H IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,; a - - P. DATE OF ISSUANCE r 0 AlAIJARZLEYS.COOPER ASSISTANT` STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERI jICES SYS MT - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERiWFSI-F_ QUNCR A_ ND SUF06RT VITAL STATISTICS rPRTTFTC ATP. ()F T)FATH - - 1 DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Momh Day Year) Dr..Stephen Wayne Maks Male February 3, 2000 4. CITY AND STATE OF BIRTH Itf not in US.A.. name countryl 5a. AGE Last Blnhday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH IMMM, Day. Year/ MOS DAYS 5c. HOURS MINS (Vrsl 5b Sedro -Woole , Washin ton 73 September 1 1926 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH HOSPITAL Inpatient OTHER ❑ Nursing Home 542 -20 -7071 ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name fff not mstifution, give street and number/ BryanLGH Medical Center East ❑ DOA ❑ Other /Specityi Sc CITY TOWN OR LOCATION OF DEATH 84 INSIDE CITY LIMITS Be. COUNTY OF DEATH Lincoln Yes ® No ❑ Lancaster 9a RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Inducting Zip Coom 9e INSIOE CITY LIMITS Nebraska Hall Grand Island 1517 Stagecoach Rd. 688 ,Yes ff] No ❑ 10. RACE - (e. g.. White. Black. American Indian. 11, ANCESTRY (e g. Italian Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /Itwde. give maiden name) etc) S cdy) Mite (Spec I tmerican NEVER DIVORCED Q. Mary Rosalyn Hartnett 14a. USUAL OCCUPATION IGrve kind of work done during most III KIND OF BUSINESS INDUSTRY t5. EDUCATION (Specify only highest grade completedl Elementary or Secondary (0 -121 Colle� `1.4 or 5.1 of working life, even d retired) 1i Health Care Physician Medical 16. FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Stephen Maks Frances Lloyd 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 1 9a INFORMANT -NAME (Yes . no. or uri III yes. give war and dales of services) Yes WWII 2 -28 -45 to 10 -25 -46 Mary Maks 190. INFORMANT MAILING ADDRESS (STREET OR R. F NO., CITY OR TOWN. STATE. ZIP) 1517 Stagecoach Rd., Grand Island, Nebraska 68801 20. EK48ALMER - SIGNATU E 6 LICEPkE NO 21 a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME ®Bumf ❑Removal Febr. 9, 2000 Black Hills National Cem. 22a. FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑Cremation ❑Donalor, Sturgis South Dakota 22b FUNERAL HOME ADDRESS (STREET OR RF.D. NO CITY OR TOWN. STATE. ZIP) 601 N. Webb Rd., Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal (b). AND cll Interval between onset and death PART I (a) Pneumonia DUE TO, OR AS A CONSEQUENCE OF Interval between onset and dear, (b) Renal Failure _— gr4ai- x than 2 it DUE TO OR AS A CONSEQUENCE OF Interval between onset an ealh (c)Chronic Obstructive Pulmonary WTMIRAP OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 2 AUTOPSY 25. WA CAS R PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER' II (Ages 70 -54) Yes F No Yes No Yes n No 26a. 26b, DATE OF INJURY IMo.. Day. Yr.) 26c HOUR OF INJURY 26d, DESCRIBE HOW INJURY OCCURRED Accident Undetermined M Suicide Pending 26e. INJURY AT WORK 261 home. )arm. street factory ?ding etAY 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Invesiganon ❑ ❑ office b BS Yes No 27a DATE OF DEATH IMo Day Yr.) 28a DATE SIGNED IMo Day Yr t 28b TIME OF DEATH February 3, 2000 �= M Q i 27b DATE SIGNED IMo. Day Yrl 27c TIME OF DEATH 28c PRONOUNCED DEAD (Mo. Day. Yr) 29d PRONOUNCED DEAD (Hour) a� gr° February 000 2:14 AM ¢az ° M < ° 27tl To the be$t 01 my owl .death curt a he ti e. le ntl Dlace and due to the 28e On the basis of examination and or investigation, in my Opinion death occurred at ca—sl slated - the time dale and place and due to the causels) stated. (Signature and Title) to (Si nature and Title) ► DID TOBACCO CONTRIBUTE HE DEATH? 30 a HAS ORGAN OR TISSUE DONATI N BEEN CONSIDERED'( 30.b WAS CONSENT GRANTED' ❑ 129 LV YES ❑ NO ❑ UNKNC) ❑ NO YES 31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEVI rType or Pnnb Bob J. Bleicher, M.D. 1500 South 48th St., Suite F,017) 32a REGISTRAR 32b DATE FIL-Eh, Y REGISTRAR /MO. Day YrJ 0"I - � FEB 9 20nn