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WHEN THIS COPY CARRIES 71E RAISED SEAL OF THE NEBRASKA HEALTH AND H0MANAFRWC#S <br />SYSTEM; IT CERTIFIES flf BELOW TO BE A TRUE COPY OF THE ORIGINAL REl 3NVFJt€� <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT 13 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =_ ; <br />DATE OF ISSUANCE <br />200105838 <br />JUN 2 51999 <br />UNCOLN, NEBRASKA HEALTH /tllrD tfAlfl~_ <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN <br />lE�iND S�PCIRT <br />VITAL STATISTICS r <br />CERTIFICATE OF DEATH <br />rn <br />O a <br />N co <br />A <br />O <br />CD <br />Q. <br />O a <br />O <br />CO2 <br />Cn C <br />Co <br />W CD <br />.�+ <br />OD � <br />O <br />17�_� <br />O <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />f7� <br />Male Ma 5 <br />4. CITY AND STATE OF BIRTH tdfn nd USA.. namecardnyl <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DA E OF BIRTH iMondt. Day Year] <br />C n <br />c� <br />(Yrs.) Sb. <br />= <br />Cl 7 2K `�� <br />c a <br />,. <br />= <br />December 14, 1903 <br />7. SOCIAL SECURTIY NUMBER <br />M <br />r) M -. <br />HOSPITAL: Inpatient OTHER. ® Nursmg Home <br />- - -- <br />(0 <br />ER Outpatient Residence <br />Bb. FACILITY - Name /M not institution. give sheet and number) <br />Francis Memorial Health Center <br />El DOA 1:1 Other(Specdvo <br />N <br />8d. INSIDE CITY LIMITS <br />Co <br />Grand Island <br />I Yes ® No ❑ <br />I <br />rn <br />ga. RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) <br />� <br />Nebraska <br />I Hall <br />c3 <br />1618 N. Walnut 68801 <br />�^ 3t► <br />10. RACE - (e.g.. White. Black. American Indian. <br />11. ANCESTRY leg. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />a <br />etc.) Specify) <br />White <br />ISPecMl <br />American <br />CD <br />Agnes A. Kment <br />CD <br />W <br />14a. USUAL OCCUPATION (Give kind ol work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br /><A <br />The Northerly Eighty Eight (88) Feet of Lots One (1) and Two (2) in Block <br />Eighteen (18), in <br />Schimmer's <br />Addition to the City of Grand Island, Hall County, Nebraska. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Hiram McGee <br />WHEN THIS COPY CARRIES 71E RAISED SEAL OF THE NEBRASKA HEALTH AND H0MANAFRWC#S <br />SYSTEM; IT CERTIFIES flf BELOW TO BE A TRUE COPY OF THE ORIGINAL REl 3NVFJt€� <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT 13 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =_ ; <br />DATE OF ISSUANCE <br />200105838 <br />JUN 2 51999 <br />UNCOLN, NEBRASKA HEALTH /tllrD tfAlfl~_ <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN <br />lE�iND S�PCIRT <br />VITAL STATISTICS r <br />CERTIFICATE OF DEATH <br />rn <br />O a <br />N co <br />A <br />O <br />CD <br />Q. <br />O a <br />O <br />CO2 <br />Cn C <br />Co <br />W CD <br />.�+ <br />OD � <br />O <br />17�_� <br />O <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX •3. DATE OF DEATH /Month. Day Year/ <br />Male Ma 5 <br />4. CITY AND STATE OF BIRTH tdfn nd USA.. namecardnyl <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DA E OF BIRTH iMondt. Day Year] <br />MOS. DAYS <br />5c. HOURS' MINS. <br />(Yrs.) Sb. <br />Omaha Nebraska <br />95 <br />I <br />December 14, 1903 <br />7. SOCIAL SECURTIY NUMBER <br />ea. PLACE OF DEATH <br />508-05-3239 <br />it. <br />HOSPITAL: Inpatient OTHER. ® Nursmg Home <br />- - -- <br />ER Outpatient Residence <br />Bb. FACILITY - Name /M not institution. give sheet and number) <br />Francis Memorial Health Center <br />El DOA 1:1 Other(Specdvo <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />I Yes ® No ❑ <br />I <br />Hall <br />ga. RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />I Hall <br />Grand Island <br />1618 N. Walnut 68801 <br />Yee © No <br />10. RACE - (e.g.. White. Black. American Indian. <br />11. ANCESTRY leg. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE td wde. give maiden name] <br />etc.) Specify) <br />White <br />ISPecMl <br />American <br />NEVER DIVORCED <br />Agnes A. Kment <br />MARRIED <br />14a. USUAL OCCUPATION (Give kind ol work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed( <br />� Element ry or Secondary I0 -121 College It 4 or 5-I <br />of working life, even it refired! Engineer <br />Railroad <br />16. FATHER -NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Hiram McGee <br />Addie Decker <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />INFORMANT - NAME <br />(Yes no. �� uok.) J (It yes. give war and dates of services) <br />T19,a <br />NO <br />nes A. McGee <br />1 Bb. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) - - <br />1618 North Walnut S 68801 <br />20.E ALMER - SIGNATURE ENS NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY - NAME <br />® Burial E] Removal <br />may 8 1999 �Westlawn <br />Memorial Park <br />22a FUNERAL HOME - NWE <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />fel- Butler -Geld <br />❑ Cremaon ❑ Donatmn <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP) <br />1123 West Second, PO Box 1195, Grand Island, NE 68802 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LIN OR Ial. Lb). AND (cl) Interval between onset and deam <br />PART <br />I <br />(al <br />s DUE TO, OR AS A CONSECILIENCE OF Interval between onset and (learn <br />I <br />IN <br />DUE TO. OR AS A CO SEQUENCE OF 10" interval between onset and deav <br />I <br />I <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A 2 <br />AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS'+ <br />EXAMINER OR CORONER <br />II <br />(Ages <br />10 -541 Yes No <br />No No <br />Yes D No <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. Yrl <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />F] Accdent F] Undetermmed <br />M <br />❑ Smcde Pending <br />26e. INJURY AT WORK <br />261. Pl.ACE OF. INJURY - At home. farm, street. factory <br />, 26g. LOCATION STREET OR R F,D. NO. CITY OR TOWN STATE <br />Eloffice <br />Homicide Investigation <br />Yes � No <br />bolding, etc. /Specs <br />27a. DATE OF DEATH tAlo. Day. Yr) <br />28a DATE SIGNED thlo.. Day Yr.; <br />281b TIME OF DEATH <br />1 <br />r <br />M <br />�s <br />27b. DATE SIGNE My. Yr.J <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD TMo. Day, YrJ <br />28d. PRONOUNCED DEAD /HOUrI <br />M <br />M <br />$ <br />8 <br />27d. To the beat my k ath turned 6me, date and dace due to the <br />uuselsl <br />28e. On the basis W examination antl,or investigation, in my opinion death occurred at <br />the time, date and Mace and due to the cause(s) stated. <br />o <br />o 8 <br />1 <br />(Signature and Tine � <br />S nature and Tito <br />29. DID TOBACCO USE CONTRIBUTE TO D ? <br />30.a A$ ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />' <br />30.b WAS CONSENT GRANTED? <br />0_-- <br />YES NO UNKNOWN <br />El YES 10 <br />YES <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type a Pr-0 <br />Gordon J. Hrnicek, M.D. 729 NW Quist <br />jth <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Ab.. Day. Yr) <br />1" • <br />MAY 121999 <br />