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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH'ANaI&WAS SERVICES
<br />SYSTEM, RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA ' WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S1 /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 21C A 1 0 5
<br />NOV 2 9 2000 �G l; COOPER -_
<br />LINCOLN, NEBRASKA HEAL 'A SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH 'HU� SERYI t [NAtNCEAND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH -
<br />- -- -- - --
<br />1 DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />- - - - - - -- --
<br />3 DATE OF DEATH hf,, r (I -r Yearl
<br />_ Donald W. Cates
<br />Male
<br />October 27, 200_0
<br />4 CI7 V AND STAT E OF RIRTH P not m U SA name country
<br />5a AGE - Lasl Bmhday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH .Monts D,v Year)
<br />Cameron, Nebraska
<br />IVrs Sb
<br />�9
<br />March 20, 1911_
<br />MOS I DAYS
<br />Sc. HOURS MINS
<br />7 SOCIAL SECURTIY NJkl8t I'
<br />8a PLACE OF DEATH
<br />505 -05 -1469
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing H „me
<br />- A - --
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name ifnot— titution. give street and number)
<br />770 North Cotner Blvd. #220
<br />❑ DOA [] Olhe,;Sped, Physicians _Off
<br />8c CITY TOWN OR LOC.�t,ON OF SEA TH
<br />8tl INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes E� No ❑
<br />Lancaster
<br />ga RESIDENCE - STATE 91 COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zip Codei
<br />9e INSIDE CITY LIMITS
<br />Apt. 234
<br />Nebraska I Lanc aster
<br />Lincoln
<br />7208 Van Dorn St.
<br />Yes X❑ No ❑
<br />10 RACE Ie.q., While Bierr, American Indian
<br />11 ANCESTRY leq Italian. Mexican. German. etc/
<br />12. a MARRIED ❑ WIDOWED
<br />73 NAME OF SPOUSE It wd, a— maiden name)
<br />etc.) lSoeoNl
<br />White
<br />ISo —tyl
<br />American
<br />NEVER DIVORCED
<br />Jean Gardiner
<br />MARRIED
<br />14a USUAL OCCUPATION i3— kind of work done dung mast 14b
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify, only Nghest grade completed)
<br />of work,ng Ide. even I rel -1
<br />(
<br />Elementary or Secondary 10 -121 College ,1 n o,
<br />Owner
<br />Cates Tire Compan 1
<br />12
<br />16 FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles Cates
<br />Caroline Matson
<br />18 WAS DECEASED r - -: , -a Ir. J S ARMED FORCES'
<br />11, INFORMANT - NAME
<br />(Yes. 1, ur unk ,I �.�1 �ve tar ar1f1 dal, of lerwc,li
<br />No
<br />I Kathy Moore
<br />- _
<br />191, INFORMANT MAILING ADDRESS 'STREET OR R F D NO. CITY OR TOWN. STATE. ZIP)
<br />2920 Sherida Blvd. Lincoln, Nebraska 68502
<br />20 EMBALM�E9- IGNATURE 3 LICENSE O
<br />21a METHODOFDISPOSITION
<br />21b. DATE
<br />CEMETERVORCREMAr'P� NAME
<br />�_ 1 ?�
<br />® Burial ❑ Removal
<br />Oct. 31, 2000
<br />Westlawn Memorial Park
<br />22a TUNERAL HOME NAME
<br />21d CEMETERY OR CREMATORY LOCATION CII v DH TOWN STATE
<br />A fel- Butler- Geddes F.H.
<br />❑Cremation 1:1 Donator,
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS ISTREET OR RF D NO CITY OR TOWN. STATE, ZIP)
<br />1123 West 2nd, Grand Island, Nebraska 68801
<br />23 IMMEDIATE CAUSE (ENTER ONLY CAUSE PER LINE FOR lal - III AND Ic11 Interval between onset aria n. a
<br />sONE
<br />PART W � � .5� l V � � 1 4' �� � V. � I � � V J S
<br />` 1 �(j
<br />al W
<br />DUE TO, OR AS A C EOUENCE OF I i—ai between onset-,, -,v,
<br />_ (bl (y AL� - tScV\ev,,- C� C�t�ekc /opn.�Gt�/ �rS
<br />(
<br />DUE TO, OR AS A CONSEUUENCE CIF mle Val between on =e. a,: J•:.i: +.
<br />C+hefv,SCle► O's IS rS
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS diuon
<br />PART
<br />contributing to the death but not related PART
<br />PREGNANCY
<br />III IF FEMALE. WAS THERE A 24
<br />IN THE PAST 3 MONTHS'
<br />AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />CL i
<br />Lk N
<br />5Q
<br />(Ages
<br />10 -54) Yes 0 No
<br />Yes No
<br />Yes No
<br />26a
<br />26b DATE OF INJURY fMO.. Day. Yr)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident I Unnetermmed
<br />I
<br />M
<br />S—de [�] P,nd g
<br />26e INJURY AT WORK
<br />261 PLACE OF INJURY - AI home. farm street. factory
<br />26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />Yes No ❑
<br />o ice bwlding. etc ISpecify)
<br />27a. DATE OF DEATH iMu Day Yrl
<br />28a. DATE SIGNED (Mo. Day Yr1
<br />281, TIME OF DEATH
<br />October 27, 2000
<br />z
<br />U5
<br />V ¢
<br />M
<br />27b DATE SIGNED IMo.. Day Yr)
<br />27c TIME OF DEATH
<br />26c. PRONOUNCED DEAD IMo.. Day. Yr)
<br />28d. PRONOUNCED DEAD /Noun
<br />EaJ
<br />exi 3t
<br />11:50 AM
<br />_
<br />o '0
<br />27d T” the best of my knowled a 4ealh Curred a ti e. d e an
<br />rid due to the
<br />28e On the basis of examination and or investigation. in my opinion death occurred at
<br />o
<br />, caul,, 1, Staled J
<br />°u = It.
<br />the time. date and place and due to the cause(s) stated.
<br />[Signature and Tale) ►
<br />ISI nature and Tittel ►
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.to
<br />WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES � NO
<br />❑ YES IS NC,
<br />31 NAME AND ADDRESS OFjFCERTFER ; PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( ;Type or Pimb
<br />H.Larry Mitchell MD 70 N Cirfl-npr RT.,%rd. sititP22 NE 68505
<br />32a REGISTRAR
<br />32b DATE FILEE1f3Y,gVSTRAR _,/&O 00l
<br />rI
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