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n <br />n D <br />•" + m cn <br />{ p h 1, � � s ti ❑ �� o r�� <br />1 IM Cn , <br />ro <br />1 (^ M rn o <br />kA q fi <br />13 <br />C? Z O <br />t �— s >. Cj <br />t _ EI <br />co Cn CD <br />C!> Co 0 <br />Lot 17, Block 1, in Southern Acres Addition to the City of Grand Island, <br />Hall Countv. Nebraska. <br />WHEN T HIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDMUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR /G /W REC RD-ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S - ttgrics&EGTION, WHICH is <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />_= �AHEEY S.: COOPER <br />MAY 15 2001 = =. ASS_ ISW# STATE 1090W. RAR <br />LINCOLN, NEBRASKA OF NEBRASKA- DEPARTMENT OF HEALTH � N SBRVIV#E,'ENS SERVICES SUPPORT 04798 <br />vrrAL STATISTICS - = V 1 <br />CERTIFICATE OF DEATH <br />I DECEDENT - NAME FIRST MIDDLE LAST <br />2 SE-X - -- --- <br />3 DATE OF DEATH /Month. Day. Mean <br />Opal Agnes Steinbeck <br />Female= <br />May-1, 2001 <br />a. CITY AND STATE OF BIRTH (It not m USA name country! <br />5a. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Year) <br />Sb MOS I DAYS <br />5c. HOURS MINS <br />Doniphan, Nebraska <br />IYr <br />�9 <br />February 6, 1922 <br />7 SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />505 -26 -0746 <br />HOSPITAL ❑ Inpatient OTHER Nursing Home <br />El Suicide ❑ Pending <br />❑ ER Outpatient ❑ Residence <br />8b FACILITY -Name (a not mstituaon, give street and number) <br />Lakeview Nursing Care Center <br />❑ DOA ❑ Other(Spec,Ni <br />Sc CITY TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />Grand Island - <br />Yes ® No ❑ <br />Hall <br />'.. 9a. RESIDENCE • STATE <br />9b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER 11ncluding Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2508 Cochin 68801 <br />Yes ❑X No ❑ <br />10. RACE - (e.g.. White. Black. American Indian <br />11. ANCESTRY Is g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE /a wde give maiden name) <br />etc .I !Specify) <br />White <br />(Specify) <br />German <br />NEVER DIVORCED <br />Hollis H. Steinbeck <br />May 2 2001 <br />1:30k <br />MARRIED <br />14a USUAL OCCUPATION (Grve Rind o/ work done dunng most <br />1 ab KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Speedy Only highest grade completed) <br />Elementary Secondary IO -t 2) College f 1.4 or 5.1 <br />A <br />of working life. even it retiredl <br />Homemaker <br />Domestic <br />16. FATHER - NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />William C. Horst <br />Emma P. Hamann <br />18. WAS DECEASED EVER IN U S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />IYes. no or unkJ If yes give war and dates of servlcesl <br />No I <br />Kenneth Steinbeck <br />19b. INFORMANT MAILING ADDRESS (STREET OR R D NO_ CITY OR TOWN. STATE. ZIP) <br />1128 North Hancock Ave., Grand Island, NE 68803 <br />20. EM LMER - SIGNATURE 6 LICENSE NO <br />21 a METHOD OF DISPOSITION <br />211b DATE 21c <br />CEMETERY OR CREMATORY NAME <br />32b DATEFILEOBy PWRAft 11.7ni <br />Burial ❑ Removal <br />May 4, 2001 <br />Cedar View Cemetery <br />22a. FUNERA HOME -NAME <br />21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler - Geddes <br />❑Cremation 11 Donator <br />Doni han, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, Nebraska 68801 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR at (b). AND (01 Interval between ousel and seam <br />PART / t <br />DUE TO, OR AS A CONSEQUENCE OF I Interval between ortylit and death <br />I <br />(b) <br />uuc 1 v. �n na a wrvacwcrvt,c ur <br />n <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A i <br />I <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS <br />EXAMINER OR CORONER' <br />II <br />IAge510 -Sal Vey No K <br />Yes No <br />Yes No <br />26a <br />26b DATE OF INJURY (Mo.. Day. Yr/ <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />ACCdIrmt [_� Lintlele rmined <br />M <br />El Suicide ❑ Pending <br />26e INJURY AT WORK <br />261 PLACE OF INJURY - At home, farm sheet. lactory <br />26g. LOCATION STREET OR R F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes No <br />❑ <br />o ¢e budding. etc (Specify) <br />27a DATE OF DEATH IMo Day Yr.) <br />28a DATE SIGNED /Mo.. Day Yr 1 <br />28b TIME OF DEATH <br />May 1 2001 <br />M <br />N <br />> ¢ <br />27b DATE SIGNED (Mo Day Y,) <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD /Mo Day. Yr.) <br />28d. PRONOUNCED DEAD (Noun <br />o <br />May 2 2001 <br />1:30k <br />A <br />M <br />° <br />g <br />27d To the best of my knowledge h occurred at the lime, date and place and due to the <br />28e. On the basis of examination and or Investigation. in my opinion death occurred at <br />¢ <br />causelsl slated <br />,. <br />the time, date and place and due to the causelsl stated. <br />Signature and Title! ► ' V <br />ISI nature and Title ► <br />29 DID TOBACCO USE CONTRIBUTE TO 1111 DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES NO ❑ UNKNOWN ❑ YES 91 NO <br />❑ YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY !Tvoe or Pr ti <br />Thomas F. Werner M.D. 2444 . Faidl y Ave., Grand Island, NE. 68803 <br />32a REGISTRAR <br />32b DATEFILEOBy PWRAft 11.7ni <br />"' - - <br />�_5 <br />\v <br />