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<br />Diane Ka Trac Female arch 1 1993
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<br />June $ 1949
<br />7. SOCIAL SECURITY NUMBER Sa PUCE OF DEATH
<br />\ HOSPITAL: ,�] Inpatient ❑ ERi0ulpaseM ❑DOA
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<br />Ob. FACILITY - Name (N not krtlluacn, 9" aeeet and nunNer) Sc . CRY, TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 84. COUNTY OF DEATH
<br />(Sri" Yes « Nol
<br />Univ. Nebr. Med- enter Omaha v__ D 1
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<br />lsifil Yes or No)
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<br />O� WIDOWED, DIVORCED (Spsc/y)
<br />Married Donald Trqcv
<br />144. USUAL OCCUPATION (Give kind d cork done during most 14b. KIND OF BUSINESS INDUSTRY
<br />M
<br />1
<br />te. FATHER -NAME FIRST MIDDLE LAST 117. MOTHER -MAIDEN NAME FIRST MIDDLE UST
<br />I& WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT -NAME - MAILI ADDRESS (STREET OR R.F.D. NO., CITY OR TOW6,((�s�IJJ A1 ,SIP)
<br />(Yes, n% or unit.) IN Yes, give war arts data Of services) 11
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<br />::2 T0, OR AS A CONSEOUENCE OF: Interval between onset and death
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE 200105733
<br />-
<br />MAR 18 1993 STANLEY 6,: , QD07Ex�-ifIRECTOR
<br />LINCOLN, NEBRASKA BUREAU 0- F_VIYAl_STATISTIC9
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS ! r
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX ATE OF DEATH /Month, Day, Yew)
<br />73.
<br />Diane Ka Trac Female arch 1 1993
<br />m
<br />(Yrs.l eb. MOS. DAYS 5[. HOURS! MINS.
<br />Grand Island, Nebraska 43
<br />June $ 1949
<br />7. SOCIAL SECURITY NUMBER Sa PUCE OF DEATH
<br />\ HOSPITAL: ,�] Inpatient ❑ ERi0ulpaseM ❑DOA
<br />_ _ OTHER ❑Nursing Home ❑ Residence O Dow (SpecMl
<br />Ob. FACILITY - Name (N not krtlluacn, 9" aeeet and nunNer) Sc . CRY, TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 84. COUNTY OF DEATH
<br />(Sri" Yes « Nol
<br />Univ. Nebr. Med- enter Omaha v__ D 1
<br />9a RESIDENCE • STATE 9b. COUNTY 9c. CRY, TOWN OR LOCATION 9d. STREET AND NUMBER (MciudwV Tip Code) 9e. INSIDE CITY LIMITS
<br />lsifil Yes or No)
<br />2
<br />D
<br />O� WIDOWED, DIVORCED (Spsc/y)
<br />Married Donald Trqcv
<br />144. USUAL OCCUPATION (Give kind d cork done during most 14b. KIND OF BUSINESS INDUSTRY
<br />of larking Ift sari N rs«ed)
<br />Co-Owner - -\\,C) Ekmery «seoWary (a1z) Cdks (1-a 0, 5*)
<br />1
<br />te. FATHER -NAME FIRST MIDDLE LAST 117. MOTHER -MAIDEN NAME FIRST MIDDLE UST
<br />I& WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT -NAME - MAILI ADDRESS (STREET OR R.F.D. NO., CITY OR TOW6,((�s�IJJ A1 ,SIP)
<br />(Yes, n% or unit.) IN Yes, give war arts data Of services) 11
<br />20a. BURIAL, Cnmaaon,Ramovp, 20b. DATE - 20d. CEMETERY OR CREMATORY - AME 20d. OCATION CITY OR TOWN STATE
<br />Donation
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<br />23. IMME TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b1, AND (c)1 I Interval between onset and death
<br />PART
<br />::2 T0, OR AS A CONSEOUENCE OF: Interval between onset and death
<br />_
<br />^?.
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<br />p
<br />tis W Yea ❑ No Q
<br />SUICIDE,,
<br />284. ACCIDENT, HOMICIDE, UNDET.. 125b. DATE OF INJURY /Mc,Day, Yr.) 26c. HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Speclly) I ]
<br />Zee. INJURY AT WORK
<br />(Specify Yes or No)
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<br />the time, date and place and due to the cause(s) stated.
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<br />29s. DID TOBACCO USE CONTRIBU O THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />y
<br />O YES ❑ NO * UNKNOWN
<br />O YES * NO
<br />7D YES d NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONERS PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE 200105733
<br />-
<br />MAR 18 1993 STANLEY 6,: , QD07Ex�-ifIRECTOR
<br />LINCOLN, NEBRASKA BUREAU 0- F_VIYAl_STATISTIC9
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS ! r
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX ATE OF DEATH /Month, Day, Yew)
<br />73.
<br />Diane Ka Trac Female arch 1 1993
<br />t. CRY AND STATE OF BIRTH (N rlpt in U.8•A., name eoul") SL AGE - Lap Blr9tday 6. DATE OF BIRTH (MpnM, Day, YNr)
<br />(Yrs.l eb. MOS. DAYS 5[. HOURS! MINS.
<br />Grand Island, Nebraska 43
<br />June $ 1949
<br />7. SOCIAL SECURITY NUMBER Sa PUCE OF DEATH
<br />\ HOSPITAL: ,�] Inpatient ❑ ERi0ulpaseM ❑DOA
<br />_ _ OTHER ❑Nursing Home ❑ Residence O Dow (SpecMl
<br />Ob. FACILITY - Name (N not krtlluacn, 9" aeeet and nunNer) Sc . CRY, TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 84. COUNTY OF DEATH
<br />(Sri" Yes « Nol
<br />Univ. Nebr. Med- enter Omaha v__ D 1
<br />9a RESIDENCE • STATE 9b. COUNTY 9c. CRY, TOWN OR LOCATION 9d. STREET AND NUMBER (MciudwV Tip Code) 9e. INSIDE CITY LIMITS
<br />lsifil Yes or No)
<br />19. RACE - (e.g.. Whits, Black, American Indian, 11. ANCESTRY (ap..Wan, Mexican, German, sic.1 12. MARRIED,NEVER MARRIED. 1 SPOUSE /N alit, pia name)
<br />MG) ISOY) ISP�M'1
<br />O� WIDOWED, DIVORCED (Spsc/y)
<br />Married Donald Trqcv
<br />144. USUAL OCCUPATION (Give kind d cork done during most 14b. KIND OF BUSINESS INDUSTRY
<br />of larking Ift sari N rs«ed)
<br />Co-Owner - -\\,C) Ekmery «seoWary (a1z) Cdks (1-a 0, 5*)
<br />1
<br />te. FATHER -NAME FIRST MIDDLE LAST 117. MOTHER -MAIDEN NAME FIRST MIDDLE UST
<br />I& WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT -NAME - MAILI ADDRESS (STREET OR R.F.D. NO., CITY OR TOW6,((�s�IJJ A1 ,SIP)
<br />(Yes, n% or unit.) IN Yes, give war arts data Of services) 11
<br />20a. BURIAL, Cnmaaon,Ramovp, 20b. DATE - 20d. CEMETERY OR CREMATORY - AME 20d. OCATION CITY OR TOWN STATE
<br />Donation
<br />Grand Island City Cemeter Grand Island Nebraska
<br />21. EMMLMEIR - SIGNATURE A QICENSE NO. 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATF61%01
<br />Livin ston- Sondermann 505 W. Koenig, Grand Island NE
<br />23. IMME TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b1, AND (c)1 I Interval between onset and death
<br />PART
<br />::2 T0, OR AS A CONSEOUENCE OF: Interval between onset and death
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Qc
<br />S
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related III IF FEMALE, WAS THERE A 24. AUTOPSY 25. WAS CASE REFER D TO MEDICAL
<br />PART
<br />1NANCY IN THE PAST 3 MONTHS? lSPed� Nol (SPedry Yes «NOIRONER?
<br />[PART
<br />II :�L,_CY11 �• hn e. �'��K.'w-.n�
<br />tis W Yea ❑ No Q
<br />SUICIDE,,
<br />284. ACCIDENT, HOMICIDE, UNDET.. 125b. DATE OF INJURY /Mc,Day, Yr.) 26c. HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Speclly) I ]
<br />Zee. INJURY AT WORK
<br />(Specify Yes or No)
<br />261. PLACE OF INJURY - At tame, farm, street factory,
<br />office building. stc. (Speciry)
<br />26p. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (Mo., Day. Yr.)
<br />` >` / /q 3
<br />28a. DATE SIGNED (Mc. Day, Yr,)
<br />28b. TIME OF DEATH
<br />a
<br />a
<br />27b. DATE SIGNED (Mo., Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mat., Day, Yr.)
<br />26d. PRONOUNCED DEAD (Hour)
<br />fig
<br />3
<br />8
<br />27d. To the beat of my k , death occurred at , date and place and due ro the
<br />Causes) stated.
<br />2Be. On the basis of examination and'« investigation, in my opinion death occurred at
<br />a
<br />the time, date and place and due to the cause(s) stated.
<br />5 e e a T ce ► M. D.
<br />Si nature and T na
<br />29s. DID TOBACCO USE CONTRIBU O THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />O YES ❑ NO * UNKNOWN
<br />O YES * NO
<br />7D YES d NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONERS PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />use ,tit (a CGS 2 `d SHer- k, c, c-!L (^ !gam
<br />«918 r /ZIWAMc
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