|
200'Mib13
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<br />O WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH MR. NLM9M SERWCiES
<br />W SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL READ -f - TH
<br />G THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />�1IHVC€Y$ COOPER
<br />JUL 5 2000 o 0 o U O b 8 9 2 ASS1#A#T stare REGISTRAR=
<br />LINCOLN, NEBRASKA HEALTH AND HWAM4EG;ItICES SYSTEIIt=
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN Ste_ .VICES MINA E AND $I#PPORT
<br />VITAL STATISTICS _> >_
<br />CERTIFICATE OF DEATH w = -
<br />t FIRS( MIDULF. LAST �EX i 3 DATF OF DEATH 1h ..1, f <'.�•.
<br />_ —US _Gettman ale June 20, 2000
<br />RNLI STATF )F 3117tH N norm US A.namecduntrvl 6a AGE -Last Bmhday UNDER YEAR UNDER DAY 6. DATE OF RIFT, Month. Dav Yearl
<br />c' IY's , 6b MOS DAYS ! x HOURS MINS
<br />,, P -- -_ -_ -1 , - - -- 8a PLACE OF DEATH
<br />Adams Count Nebraska 83
<br />clA�secuRnr auMBC
<br />HOSPITAL Iocavenl OTHER ❑ Nurs,ny Horn•
<br />508 -48 -0572
<br />Bb FACILITY Name (Itni,,4htutrdn. orve street and number) ER Outpatient Res,denca
<br />I El DOA Other ; Soe,,,;
<br />ome -515 0 _-W p q t_ ._ 7 n h tee _ _ - -- - -- _ --
<br />8r. CITY TOWN OR 1 OCA T,()N OF DEATH �dC INSIDE CITY LIMIT$ 8e COUNTY OF DEATH
<br />Yes ❑ No .9 Adams _
<br />j9a RESIDENCE 9b COUNTY 9e CITY. TOWN OR LOCATION 9C STREET AIJD NLMBER 'In 1N$ID r'TV trAIIS
<br />o RANebraskaer,canlntl,an Adams Kenesaw
<br />le Italian, Kenesaw 1 51 50 WEst 76�A5 §t r
<br />I � Ye5
<br />1 I Mexican. German. eta 12. MARRIED All DINED 73 NAME OF SPOUSE Ot wile glue madan Hamel
<br />etc I'Sneotyi Soec,IVI NEVER DIVORCED
<br />Caucasian- �_- German MARR Leola Kroll_ _
<br />I JSUAL OCCUPATION ,Give.md of work done during most 14b KIND OF BUSINESS INDUSTRY iS EDUCATION !Specrty only mgherst grade completed) - -_
<br />W wn�.,ng ode even d rawedr Elementary a Secondary 10121 Colie9e r a o•
<br />Farmer Agricultbre 8
<br />--ITT A7L ER Ni,ME FIRST MIDDLE LAST .MOTHER FIRST MIDDLE MAIDr N SU HNAME
<br />. -._ - attman 5 D °CE ASF) -v Fh ,N �I� A FORCES , t9a INFORMANT -NAME
<br />e, n, ..,, I, ,.. .4.m war ano dales of serv,cesl
<br />7(✓�
<br />J Leola Gettman
<br />�f9D l7MANT MAIL IN.a AD DRESS STREET OR RF J NOCITY OR TOWN STATE. ZIP)
<br />1515& W-e- s- t--U-tli ST _--- _Kates- ��asa_1�i
<br />C 2ll r: FjA�'.irF , t Na , RE R LICENSE NO 27a METHOD OF DIC_POSIPON 21b DATE. - -.._. T2rc CEfIFTERV OR CR.�Mgi GR. NAME..
<br />i
<br />i'�•�r(,I. z�r� -ll �Bnra, ❑Remna ��I,nP 20001 Concordia Cemeter-y-_ _
<br />2;1i` ONERAL HOME NAME., 21tl CEMETERY OR „REMATORv LOCATION CITY OR TOWN STAT-
<br />Jackson - Wilson F.H. ❑Crematon ❑Donator _ Juniata, Nebraska
<br />2b F" %ERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP)
<br />I
<br />N. -Smith Avenue Kenesaw, Nebraska 68956 _
<br />23 ,MMEDIA (E CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal Ibl. AND (01 Interval between tinsel anti
<br />PART -
<br />a.
<br />Coronary accident Immediate
<br />DUE 10. OR AS A CONSEOUENCE OF Interval between on.,el a _ -
<br />'b•
<br />C'HER NUNIFICANT CONDITIONS Conditions contributing to the death bu, not related PART III IF FEMALE WAS THERE A 2a AUTOPSY
<br />PAR, PREGNANCY IN THE PAST 3 MCNTHS'r
<br />;Ages 10 54) Yes 1-7 v
<br />No X
<br />Yes
<br />_No
<br />T 26b DATE OF INJURY (Mo Day ✓rl 26c HOUR OF INJURY 1 26d DESCRIBE HOW INJURY OCCURRED
<br />i te�_anp��
<br />26. WAS CASE REFERRED-, ) b1FDIC AI.
<br />EXAMINER OR COR )N
<br />— ves _
<br />26..
<br />Natural
<br />FJAcC.. l . Aelevn.ned . —�-- —__ —_ --ST
<br />P, dmG 26e ! NJURY AT WORK 261 P ACE % INJURY At lope. far, . soeet' factory 26g LOCATION REET OR RID NO CITY OR TOWN
<br />o�,Je bur etc 'SoeC,
<br />' l cdE vest,garon I Yes n No
<br />'a "'F DEATH ,MO Day Yrl 28a LATE SIGNET IMO DaV Yrl 2bn TIME OF DEATH
<br />hD r <' June 28, 2000 11:30
<br />a SIGNED rMO Day Yr' —_r 27c. TIME OF DEATH $ f° 28c °RONOUNCED DEAD lMo.. Day, Yr! 28d. PRONOUNCE) DEAD r.
<br />v " $ _
<br />E > =ao June 20, 2000 1:10 p
<br />- - --
<br />M � v,
<br />d
<br />27.1 T: de I of my knowledge death orcu'red at the time, date and olace and due :n the 1� 28e. On the DaS�s of e•aminauon and or invesugalwn. ,n my oVln,on. dealh.d -cuLre • Jk I - - U
<br />,rated .. - me time. date and olace and due to the cat elsl stated. �� TpTQ 7•``�:(`I/
<br />Y.S�rnamre and Title)
<br />►
<br />(Signature and tine) ► •
<br />29 DID TOBACC O JSF CONTRIBUTE TO THE DEATHS 30 a HAS ORGAN OR ,ISSUE DONATION BEEN CONSIDERED' 30 b WAS CONSENT GRANTED'
<br />';rn ❑ NO ® UNKNOWN I ❑ YES ® NO El YES
<br />r31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, (Type or PrIno
<br />I Meredith Oakes Peterson, Dgputy County Attorney__ P.O. Box 71, iiastin s, NE 68901
<br />32D. DATE FILED BY REGISTRAR (Mo.. Day Y0
<br />JUL _ 3 2000
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<br />O WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH MR. NLM9M SERWCiES
<br />W SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL READ -f - TH
<br />G THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />�1IHVC€Y$ COOPER
<br />JUL 5 2000 o 0 o U O b 8 9 2 ASS1#A#T stare REGISTRAR=
<br />LINCOLN, NEBRASKA HEALTH AND HWAM4EG;ItICES SYSTEIIt=
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN Ste_ .VICES MINA E AND $I#PPORT
<br />VITAL STATISTICS _> >_
<br />CERTIFICATE OF DEATH w = -
<br />t FIRS( MIDULF. LAST �EX i 3 DATF OF DEATH 1h ..1, f <'.�•.
<br />_ —US _Gettman ale June 20, 2000
<br />RNLI STATF )F 3117tH N norm US A.namecduntrvl 6a AGE -Last Bmhday UNDER YEAR UNDER DAY 6. DATE OF RIFT, Month. Dav Yearl
<br />c' IY's , 6b MOS DAYS ! x HOURS MINS
<br />,, P -- -_ -_ -1 , - - -- 8a PLACE OF DEATH
<br />Adams Count Nebraska 83
<br />clA�secuRnr auMBC
<br />HOSPITAL Iocavenl OTHER ❑ Nurs,ny Horn•
<br />508 -48 -0572
<br />Bb FACILITY Name (Itni,,4htutrdn. orve street and number) ER Outpatient Res,denca
<br />I El DOA Other ; Soe,,,;
<br />ome -515 0 _-W p q t_ ._ 7 n h tee _ _ - -- - -- _ --
<br />8r. CITY TOWN OR 1 OCA T,()N OF DEATH �dC INSIDE CITY LIMIT$ 8e COUNTY OF DEATH
<br />Yes ❑ No .9 Adams _
<br />j9a RESIDENCE 9b COUNTY 9e CITY. TOWN OR LOCATION 9C STREET AIJD NLMBER 'In 1N$ID r'TV trAIIS
<br />o RANebraskaer,canlntl,an Adams Kenesaw
<br />le Italian, Kenesaw 1 51 50 WEst 76�A5 §t r
<br />I � Ye5
<br />1 I Mexican. German. eta 12. MARRIED All DINED 73 NAME OF SPOUSE Ot wile glue madan Hamel
<br />etc I'Sneotyi Soec,IVI NEVER DIVORCED
<br />Caucasian- �_- German MARR Leola Kroll_ _
<br />I JSUAL OCCUPATION ,Give.md of work done during most 14b KIND OF BUSINESS INDUSTRY iS EDUCATION !Specrty only mgherst grade completed) - -_
<br />W wn�.,ng ode even d rawedr Elementary a Secondary 10121 Colie9e r a o•
<br />Farmer Agricultbre 8
<br />--ITT A7L ER Ni,ME FIRST MIDDLE LAST .MOTHER FIRST MIDDLE MAIDr N SU HNAME
<br />. -._ - attman 5 D °CE ASF) -v Fh ,N �I� A FORCES , t9a INFORMANT -NAME
<br />e, n, ..,, I, ,.. .4.m war ano dales of serv,cesl
<br />7(✓�
<br />J Leola Gettman
<br />�f9D l7MANT MAIL IN.a AD DRESS STREET OR RF J NOCITY OR TOWN STATE. ZIP)
<br />1515& W-e- s- t--U-tli ST _--- _Kates- ��asa_1�i
<br />C 2ll r: FjA�'.irF , t Na , RE R LICENSE NO 27a METHOD OF DIC_POSIPON 21b DATE. - -.._. T2rc CEfIFTERV OR CR.�Mgi GR. NAME..
<br />i
<br />i'�•�r(,I. z�r� -ll �Bnra, ❑Remna ��I,nP 20001 Concordia Cemeter-y-_ _
<br />2;1i` ONERAL HOME NAME., 21tl CEMETERY OR „REMATORv LOCATION CITY OR TOWN STAT-
<br />Jackson - Wilson F.H. ❑Crematon ❑Donator _ Juniata, Nebraska
<br />2b F" %ERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP)
<br />I
<br />N. -Smith Avenue Kenesaw, Nebraska 68956 _
<br />23 ,MMEDIA (E CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal Ibl. AND (01 Interval between tinsel anti
<br />PART -
<br />a.
<br />Coronary accident Immediate
<br />DUE 10. OR AS A CONSEOUENCE OF Interval between on.,el a _ -
<br />'b•
<br />C'HER NUNIFICANT CONDITIONS Conditions contributing to the death bu, not related PART III IF FEMALE WAS THERE A 2a AUTOPSY
<br />PAR, PREGNANCY IN THE PAST 3 MCNTHS'r
<br />;Ages 10 54) Yes 1-7 v
<br />No X
<br />Yes
<br />_No
<br />T 26b DATE OF INJURY (Mo Day ✓rl 26c HOUR OF INJURY 1 26d DESCRIBE HOW INJURY OCCURRED
<br />i te�_anp��
<br />26. WAS CASE REFERRED-, ) b1FDIC AI.
<br />EXAMINER OR COR )N
<br />— ves _
<br />26..
<br />Natural
<br />FJAcC.. l . Aelevn.ned . —�-- —__ —_ --ST
<br />P, dmG 26e ! NJURY AT WORK 261 P ACE % INJURY At lope. far, . soeet' factory 26g LOCATION REET OR RID NO CITY OR TOWN
<br />o�,Je bur etc 'SoeC,
<br />' l cdE vest,garon I Yes n No
<br />'a "'F DEATH ,MO Day Yrl 28a LATE SIGNET IMO DaV Yrl 2bn TIME OF DEATH
<br />hD r <' June 28, 2000 11:30
<br />a SIGNED rMO Day Yr' —_r 27c. TIME OF DEATH $ f° 28c °RONOUNCED DEAD lMo.. Day, Yr! 28d. PRONOUNCE) DEAD r.
<br />v " $ _
<br />E > =ao June 20, 2000 1:10 p
<br />- - --
<br />M � v,
<br />d
<br />27.1 T: de I of my knowledge death orcu'red at the time, date and olace and due :n the 1� 28e. On the DaS�s of e•aminauon and or invesugalwn. ,n my oVln,on. dealh.d -cuLre • Jk I - - U
<br />,rated .. - me time. date and olace and due to the cat elsl stated. �� TpTQ 7•``�:(`I/
<br />Y.S�rnamre and Title)
<br />►
<br />(Signature and tine) ► •
<br />29 DID TOBACC O JSF CONTRIBUTE TO THE DEATHS 30 a HAS ORGAN OR ,ISSUE DONATION BEEN CONSIDERED' 30 b WAS CONSENT GRANTED'
<br />';rn ❑ NO ® UNKNOWN I ❑ YES ® NO El YES
<br />r31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, (Type or PrIno
<br />I Meredith Oakes Peterson, Dgputy County Attorney__ P.O. Box 71, iiastin s, NE 68901
<br />32D. DATE FILED BY REGISTRAR (Mo.. Day Y0
<br />JUL _ 3 2000
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<br />;0,,��
<br />O WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH MR. NLM9M SERWCiES
<br />W SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL READ -f - TH
<br />G THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />�1IHVC€Y$ COOPER
<br />JUL 5 2000 o 0 o U O b 8 9 2 ASS1#A#T stare REGISTRAR=
<br />LINCOLN, NEBRASKA HEALTH AND HWAM4EG;ItICES SYSTEIIt=
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN Ste_ .VICES MINA E AND $I#PPORT
<br />VITAL STATISTICS _> >_
<br />CERTIFICATE OF DEATH w = -
<br />t FIRS( MIDULF. LAST �EX i 3 DATF OF DEATH 1h ..1, f <'.�•.
<br />_ —US _Gettman ale June 20, 2000
<br />RNLI STATF )F 3117tH N norm US A.namecduntrvl 6a AGE -Last Bmhday UNDER YEAR UNDER DAY 6. DATE OF RIFT, Month. Dav Yearl
<br />c' IY's , 6b MOS DAYS ! x HOURS MINS
<br />,, P -- -_ -_ -1 , - - -- 8a PLACE OF DEATH
<br />Adams Count Nebraska 83
<br />clA�secuRnr auMBC
<br />HOSPITAL Iocavenl OTHER ❑ Nurs,ny Horn•
<br />508 -48 -0572
<br />Bb FACILITY Name (Itni,,4htutrdn. orve street and number) ER Outpatient Res,denca
<br />I El DOA Other ; Soe,,,;
<br />ome -515 0 _-W p q t_ ._ 7 n h tee _ _ - -- - -- _ --
<br />8r. CITY TOWN OR 1 OCA T,()N OF DEATH �dC INSIDE CITY LIMIT$ 8e COUNTY OF DEATH
<br />Yes ❑ No .9 Adams _
<br />j9a RESIDENCE 9b COUNTY 9e CITY. TOWN OR LOCATION 9C STREET AIJD NLMBER 'In 1N$ID r'TV trAIIS
<br />o RANebraskaer,canlntl,an Adams Kenesaw
<br />le Italian, Kenesaw 1 51 50 WEst 76�A5 §t r
<br />I � Ye5
<br />1 I Mexican. German. eta 12. MARRIED All DINED 73 NAME OF SPOUSE Ot wile glue madan Hamel
<br />etc I'Sneotyi Soec,IVI NEVER DIVORCED
<br />Caucasian- �_- German MARR Leola Kroll_ _
<br />I JSUAL OCCUPATION ,Give.md of work done during most 14b KIND OF BUSINESS INDUSTRY iS EDUCATION !Specrty only mgherst grade completed) - -_
<br />W wn�.,ng ode even d rawedr Elementary a Secondary 10121 Colie9e r a o•
<br />Farmer Agricultbre 8
<br />--ITT A7L ER Ni,ME FIRST MIDDLE LAST .MOTHER FIRST MIDDLE MAIDr N SU HNAME
<br />. -._ - attman 5 D °CE ASF) -v Fh ,N �I� A FORCES , t9a INFORMANT -NAME
<br />e, n, ..,, I, ,.. .4.m war ano dales of serv,cesl
<br />7(✓�
<br />J Leola Gettman
<br />�f9D l7MANT MAIL IN.a AD DRESS STREET OR RF J NOCITY OR TOWN STATE. ZIP)
<br />1515& W-e- s- t--U-tli ST _--- _Kates- ��asa_1�i
<br />C 2ll r: FjA�'.irF , t Na , RE R LICENSE NO 27a METHOD OF DIC_POSIPON 21b DATE. - -.._. T2rc CEfIFTERV OR CR.�Mgi GR. NAME..
<br />i
<br />i'�•�r(,I. z�r� -ll �Bnra, ❑Remna ��I,nP 20001 Concordia Cemeter-y-_ _
<br />2;1i` ONERAL HOME NAME., 21tl CEMETERY OR „REMATORv LOCATION CITY OR TOWN STAT-
<br />Jackson - Wilson F.H. ❑Crematon ❑Donator _ Juniata, Nebraska
<br />2b F" %ERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP)
<br />I
<br />N. -Smith Avenue Kenesaw, Nebraska 68956 _
<br />23 ,MMEDIA (E CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal Ibl. AND (01 Interval between tinsel anti
<br />PART -
<br />a.
<br />Coronary accident Immediate
<br />DUE 10. OR AS A CONSEOUENCE OF Interval between on.,el a _ -
<br />'b•
<br />C'HER NUNIFICANT CONDITIONS Conditions contributing to the death bu, not related PART III IF FEMALE WAS THERE A 2a AUTOPSY
<br />PAR, PREGNANCY IN THE PAST 3 MCNTHS'r
<br />;Ages 10 54) Yes 1-7 v
<br />No X
<br />Yes
<br />_No
<br />T 26b DATE OF INJURY (Mo Day ✓rl 26c HOUR OF INJURY 1 26d DESCRIBE HOW INJURY OCCURRED
<br />i te�_anp��
<br />26. WAS CASE REFERRED-, ) b1FDIC AI.
<br />EXAMINER OR COR )N
<br />— ves _
<br />26..
<br />Natural
<br />FJAcC.. l . Aelevn.ned . —�-- —__ —_ --ST
<br />P, dmG 26e ! NJURY AT WORK 261 P ACE % INJURY At lope. far, . soeet' factory 26g LOCATION REET OR RID NO CITY OR TOWN
<br />o�,Je bur etc 'SoeC,
<br />' l cdE vest,garon I Yes n No
<br />'a "'F DEATH ,MO Day Yrl 28a LATE SIGNET IMO DaV Yrl 2bn TIME OF DEATH
<br />hD r <' June 28, 2000 11:30
<br />a SIGNED rMO Day Yr' —_r 27c. TIME OF DEATH $ f° 28c °RONOUNCED DEAD lMo.. Day, Yr! 28d. PRONOUNCE) DEAD r.
<br />v " $ _
<br />E > =ao June 20, 2000 1:10 p
<br />- - --
<br />M � v,
<br />d
<br />27.1 T: de I of my knowledge death orcu'red at the time, date and olace and due :n the 1� 28e. On the DaS�s of e•aminauon and or invesugalwn. ,n my oVln,on. dealh.d -cuLre • Jk I - - U
<br />,rated .. - me time. date and olace and due to the cat elsl stated. �� TpTQ 7•``�:(`I/
<br />Y.S�rnamre and Title)
<br />►
<br />(Signature and tine) ► •
<br />29 DID TOBACC O JSF CONTRIBUTE TO THE DEATHS 30 a HAS ORGAN OR ,ISSUE DONATION BEEN CONSIDERED' 30 b WAS CONSENT GRANTED'
<br />';rn ❑ NO ® UNKNOWN I ❑ YES ® NO El YES
<br />r31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, (Type or PrIno
<br />I Meredith Oakes Peterson, Dgputy County Attorney__ P.O. Box 71, iiastin s, NE 68901
<br />32D. DATE FILED BY REGISTRAR (Mo.. Day Y0
<br />JUL _ 3 2000
<br />Q
<br />
|