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WHEN THIS COPY CAN ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM "36151110"s SYSTEM, IT CERTIFIES T14E BELOW TO BE A TRUE COPY OF THE ORIGINAL REC(MQ_QA7 - THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICI- THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE y _ r��LQ�1��1NLEYS� JUN 212001 2 0 010 6191 ASSISTViP STATE REG*rR & LINCOLN, NEBRASKA HEALTH AND HUA1 NSERIIIES_ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERW_G- _MA AI> SUPMT VITAL STATISTICS �z- 06614 CERTIFICATE OF F DEATH DEATH V � 1 DECEDENT -NAME FIRST MIDDLE LAST 2. SEX . 3. DATE OF DEATH ( in Day. Year) Wayne Roy Holoch Male rn h n UNDER t YEAR UNDER 1 DAY 16 . DATE OF BIRTH (Month. Day Year) EXAMINER OR CORONER? (Yrs.) (Ages 10 -54) Yes No 5b. MOS DAYS Sc. HOURS MINS MCCool Junction Nebraska 78 I 26c HOUR OF INJURY m CA _o 7. SOCIAL SECURTIY NUMBER Be . PLACE OF DEATH <D � o rr Bever) Healthcare t Lakeview ❑ DOA ❑ Other (Specify) 8c. CITY. TOWN OR LOCATION OF DEATH 8tl. INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes �No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Lp Code/ 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1405 Hwy 34 W, 68801 Yes ® No ❑ 10. RACE - (e.g., White. Black, American Indian. 11. ANCESTRY fe.g.. Italian. Mexican. German, etc) 12. ,Rg MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (If wile. give maiden name) etc.) (Specify) White White !CI /Norwegian 1� NEVER DIVORCED Helen Sullivan > "7 111 n= 7C 14a. USUAL OCCUPATION (Give kind of work done dung most N t 5 EDUCATION (Specify only highest grade completed) NN, off` z fV "dC O O co Mabel Charlotte Halverson � 19a. INFORMANT -NAME (Yes ink.) 015(15%1943 50V19 1946 Helen Holoch 19b. INFORMANT MAILING ADDRESS (STREET OR R F . NO.. CITY OR TOWN. STATE. ZIP) 2515 Delwnte Avenue. Grand Island Nebraska 68803 20. ALMER - SIGNATURE d LICENS O. -Yl Q7 O �'"� Q ® Burial ❑ Removal June 13 2001 ' Pleasant Ridge Cemetery 22a. FUNERAL HOME -NAME - 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Hone ❑ Cremation ❑ Donation McCool Junction, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP( 3213 W. North Front Street Grand Island Nebraska 68803 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (bt AND (c)) Interval between onset and death rr1 O � JUN 2 0 2001 r ra cES P-A N x Cn F- Q co CD 09 M WHEN THIS COPY CAN ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM "36151110"s SYSTEM, IT CERTIFIES T14E BELOW TO BE A TRUE COPY OF THE ORIGINAL REC(MQ_QA7 - THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICI- THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE y _ r��LQ�1��1NLEYS� JUN 212001 2 0 010 6191 ASSISTViP STATE REG*rR & LINCOLN, NEBRASKA HEALTH AND HUA1 NSERIIIES_ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERW_G- _MA AI> SUPMT VITAL STATISTICS �z- 06614 CERTIFICATE OF F DEATH DEATH V � 1 DECEDENT -NAME FIRST MIDDLE LAST 2. SEX . 3. DATE OF DEATH ( in Day. Year) Wayne Roy Holoch Male June 9, 2001 a. CITY AND STATE OF BIRTH /ll notin USA. name country) 5a. AGE -Last Birthday I UNDER t YEAR UNDER 1 DAY 16 . DATE OF BIRTH (Month. Day Year) EXAMINER OR CORONER? (Yrs.) (Ages 10 -54) Yes No 5b. MOS DAYS Sc. HOURS MINS MCCool Junction Nebraska 78 I 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED October 21 1922 7. SOCIAL SECURTIY NUMBER Be . PLACE OF DEATH 508 -16 -6366 HOSPITAL. ❑ Inpatient OTHER. Nursing Home - - - - ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (If not institution, give street and number) Bever) Healthcare t Lakeview ❑ DOA ❑ Other (Specify) 8c. CITY. TOWN OR LOCATION OF DEATH 8tl. INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes �No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Lp Code/ 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1405 Hwy 34 W, 68801 Yes ® No ❑ 10. RACE - (e.g., White. Black, American Indian. 11. ANCESTRY fe.g.. Italian. Mexican. German, etc) 12. ,Rg MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (If wile. give maiden name) etc.) (Specify) White White !CI /Norwegian 1� NEVER DIVORCED Helen Sullivan 28d. PRONOUNCED DEAD (Hour) "7 MARRIED � } 14a. USUAL OCCUPATION (Give kind of work done dung most 1 ab. KIND OF BUSINESS INDUSTRY t 5 EDUCATION (Specify only highest grade completed) of working fife, even if retired) Truck Driver Distill Elementary or Seconder 10 -12) - College 11 -4 or 5.1 11th Grade 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Roy ,.7ohn Holoch Mabel Charlotte Halverson 18. WAS DECEASED EVER IN US, ARMED FORCES? 19a. INFORMANT -NAME (Yes ink.) 015(15%1943 50V19 1946 Helen Holoch 19b. INFORMANT MAILING ADDRESS (STREET OR R F . NO.. CITY OR TOWN. STATE. ZIP) 2515 Delwnte Avenue. Grand Island Nebraska 68803 20. ALMER - SIGNATURE d LICENS O. 21a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME Q ® Burial ❑ Removal June 13 2001 ' Pleasant Ridge Cemetery 22a. FUNERAL HOME -NAME - 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Hone ❑ Cremation ❑ Donation McCool Junction, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP( 3213 W. North Front Street Grand Island Nebraska 68803 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (bt AND (c)) Interval between onset and death PART `y�^' /'-� 32b. DATE FILED BY REGISTRAR (Mo. Day Yr) DUE TO, OR AS A CONSEQUENCE OF. f I Interval between onset and death I (bl DUE TO, OR AS A CONSEQUENCE OF Interval bemeen onset and death (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but hot related PART III IF FEMALE. WAS THERE A AUTOPSY 2X WAS CASE REFERRED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Ages 10 -54) Yes No Yes No Yes D No 26a. 26b. DATE OF INJURY (Mo. Day. Yr.) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ❑ Accident F] Undele-ned M ❑ Suicide F] Pending 26e INJURY AT WORK 261. Puree buQild INJURY -S t home. [arm. street. factory L�q 26g. LOCATION STREET OR R F.D. NO. CITY OR TOWN STATE Homicide Investigation ❑❑ Yes No ❑ ng. ( peci, 2 a. DATE O_ FFEATH l oo^ Day. Yr.) 28a. DATE SIGNED (MO_ Day Yr) 281, TIME OF DEATH M T r DATE SIGNED /MO.. Day Yr) �Zc. TIME OF DEATH 28c. PRONOUNCED DEAD lMo.. Day. Yr) 28d. PRONOUNCED DEAD (Hour) i� � } a N a °G To the 27 To the 5101 my nowledge. death occurred a time, oat d IN due 10 the 28e. On the basis of examination andor investigation, in my opinion death occurred at f e a ° a° ~ x- stated. ° the time, date place and due to the rogation stated. 151 nature and Title) ► (Si nature and Title) ► DID TOBACCO USE CONTRIBUTE TO THE D6AA ? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? WAS CONSENT GRANTED? ❑ YES �JO ❑ UNKNOWN ❑ YES P__Rb ❑ YES �NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Pdntl Gordon _79Q N. Custer Grand I 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo. Day Yr) JUN 2 0 2001 a "s a,