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;0 n n rn <br />T = D o c� cn .�« C:D CD <br />rf5 D (7) <br />° -r o to <br />Gi ° oo <br />-,; <br />col <br />M CD <br />j7 I XT <br />M N n I-• <br />ry <br />cn <br />all ill lV e <br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MWWWRWfCE18 <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R4PTWPII,f1LEzfflTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_ 3'ECT10N, iS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE ► _ N a <br />JUN 2 2000 200105818 <br />ASSrjt*Wr STATE REOrsjMR _. <br />LINCOLN, NEBRASKA HEALTH AND HfIMAM -Se RI/ M $T4 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEKWC €S FWAfTM AND4W1P T <br />VITAL STATISTICS _ U 00858 <br />CERTIFICATE OF DEATH - <br />- <br />_-FIRST <br />1 DECEDENT NAME <br />- — <br />MIDDLE LAST <br />2 SEX <br />- - -- - - <br />3. DATE OF DEATH ;Mann` Dav ✓earl <br />Elizabeth Purtell Ingoldsby <br />Female <br />January 10, 2000 <br />4 CITY AND STATE OF BIRTH l(f not in USA. name couril l <br />�Y Yes No <br />Sa AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />6. DATE OF BIRTH !Mont. Dal, !'earl <br />lYrsl <br />M <br />5b Mos DAYS <br />5c. HOURS MINS <br />Omaha, Nebraska <br />261 PLACE OF INJURY - M fame, term street factory <br />80 <br />nHonucide I- 0clabon <br />Yes No <br />❑ ❑ <br />October 13,_1919 <br />I SOCIAL SECURITY NUMBER <br />8a PLACE OF DEATH <br />-- <br />507 -03 -3867 <br />HOSPITAL ❑ Inpatient <br />- <br />OTHER ® Nursing <br />- <br />8b FACILITY Name (If not Insblufion, give 5freer and numw ❑ ER Outpatient ❑ Resitlence <br />Ste:- Skilled Care <br />Center ❑ DOA ❑ Other ,Spe td <br />_Francis <br />CITY FOWN OR LOCATION OF DEATH <br />Btl. INSIT3E CIMTTS Be- LDOIJT'y O UUeATH - —�.- -- - <br />18c <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />M <br />9a RESIDENCE - STATE <br />91, COUNTY <br />27b DATE SIGNED /Mo. Day Yrl <br />9c CITY TOWN OR LOCATION <br />_ <br />9d STREET AND NUMBER /lncluding Zrp Codel 9e INSIDE E CITY LIMITS <br />28d. PRONOUNCED DEAD /Hour) <br />Nebraska <br />Hall <br />9:50 .m.M <br />Grand Island <br />220 E. 20th St. 68801 Yes ® No ❑ <br />M <br />10 RACE leg.. While. Black. American Indian. <br />11. ANCESTRY le q. Italian. Mexican. German, all <br />12 ❑ MARRIED <br />® WIDOWED <br />13 NAME OF SPOUSE 11f wde grve maiden name/ <br />° T <br />etc I ispecify) <br />_ White <br />(Soecdyl <br />American <br />NEVER <br />MARRIED <br />DIVORCED <br />Les Ingoldsby <br />14a t/SUAL OCCUPATION (Give kind of work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />19 nature and Title) It. e <br />_ <br />15 EDUCATION (Specify Only highest grade completed) <br />I <br />of wndang Die . even d,eered, <br />Owner <br />29 DID TOBACCO USE CONTRIBUT15TO THE DEATH? <br />Ceramic Shop <br />_ <br />30.b WAS CONSENT GRANTED, <br />i Elementary or Secondary 10 121 College l d or S <br />12th Grade <br />16 FATHER NAME FIRST MIDDLE LAST <br />17 MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Arthur <br />Purtell <br />Anna <br />Burda <br />_ <br />'6 :`/AS DECEASED EVER IN US ARMED FORCES? <br />19a INFORMANT NAME <br />'Y_ i ol ink j III yes give war arld dates of ;ernc851 <br />No -- - - - - -- <br />I <br />_ j Tim Ingoldsby <br />- Son <br />t yp !— UHMANI MAILINU AUUHEJJ i5l Httl UH H. F U NU.. 1;11 Y UH IOWN, S I A I E. 211'1 <br />1 ill d., ,Shoreham, New York 11786 <br />I20 E ER - SIGNATURE JCEN O / 21a METHODOF DISPOSITION 21b DATE 21c CEMETERY ORCREMATOPY NAME <br />/b ❑X Burial F-] Removal Jan. 13, 20001 Westlawn Memorial Park _ <br />22a L <br />FUNERAL HO d ME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />422UNERAL ivin ston- Sondermann F.H. ❑CremaUgn ❑Donalipn Grand Island, Nebraska <br />HOME ADDRESS (STREET OR RE D NO CITY OR TOWN STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23 IMMEDIATE CA%USE —_/ (ENTER ONLY ONE PER LINE FFOOR lal. Ibl. AND Icll Interval between onset and dearth, <br />R(at �/� r /``./ LJ %%'/ i /C_ / /.J i / O�' �P/A /c �/!i'a.L .�3 • r/1 /� '� /gyp <br />DUE TO. OR A A CONSEOUENC OF Interval oemeen onset and death <br />lot <br />I <br />Interval between On5P,1 and death <br />OTHER SIGNIFICAW CONDITIONS Conditions contribuling to the death out not related PART <br />III IF FEMALE. WAS THERE A 24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS' <br />EXAMINER OR CORONER'+ <br />F <br />(Ages 10541 Yes No Yes No <br />EL <br />�Y Yes No <br />26a 261, DATE OF INJURY (MO. Day Yrl <br />26C HOUR OF INJURY <br />26d DESCRIBE HOW INJURY O .URRED <br />Arcidenl Untlelermined <br />M <br />Smade Pendmq <br />26e INJURY AT WORK <br />261 PLACE OF INJURY - M fame, term street factory <br />- <br />26g. LOCATION STREET OR R 0 NO. CITY OR TOWN STATE <br />nHonucide I- 0clabon <br />Yes No <br />❑ ❑ <br />once building, etc /Seel <br />-27a DATE OF DEATH IMo Day Yr) <br />28a. DATE SIGNED fMo Day. YrI <br />28b TIME OF DEATH <br />k January 10, 2000 <br />M <br />� s <br />$ i <br />a <br />27b DATE SIGNED /Mo. Day Yrl <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD /Mo.. Day, Yrl <br />28d. PRONOUNCED DEAD /Hour) <br />'X'January 11,2000 <br />9:50 .m.M <br />g = =� <br />M <br />27d To the best of my knowledge death occ ,red at the ti antl place due to the <br />28e. On the basis of examination and or investigallOn. In my opinion deem occurred at <br />- r <br />° T <br />causelsi stated / �./� <br />the time date and place and due to the Cause(51 stated. <br />ms <br />l _ <br />19 nature and Title) It. e <br />(Signature and Tale) Ii <br />29 DID TOBACCO USE CONTRIBUT15TO THE DEATH? <br />30 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED, <br />_ <br />30.b WAS CONSENT GRANTED, <br />X 1:1 YES (� NO ❑ UNKNOWN <br />NO <br />k " 1:1 <br />E] YES NO <br />E] <br />31 NAME AND AD —_ DRESS OFF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( IType or Prin! <br />Dr. Jane McDonald 800 Alpha Street Grand Island, NE 68803 <br />32a REGISTRAR <br />_ <br />320 DATE FILED BY REGISTRAR (Mo. y. Yrl <br />JAN 13 20Da00 <br />