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200106647 rev. 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH ' o Q U r C 7 O � U O N E f0 X I2 ( a) Z E w � C w .fO U w rn .0 LL a O w y Q O Z LL C0 co 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Month. Day. Year) Max Myri Thomas Male I March 10 2001 4. CITY AND STATE OF BIRTH 11/nol in U.S.A.. name country! 5a. AGE - Last Birthday UNDER t YEAR UNDER 1 DAY 8. DATE OF BIRTH 1MonM. Day. Year) Olney, IL (Yrs.l Sb. MOS. i DAYS 5c. HOURS' MIN$. Yes 0 No 78 26a. December 20 1922 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 347 -16 -1724 HOSPITAL: ❑ Inpatient OTHER: Nursing Home -- - ❑ ER Outpatient ❑ Residence 8b. FACILITY -Name 11f not instiluf an, give street and number) St. Francis Memorial Health ❑ ODA ❑ Other(Speo(vl 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island, vea ® Nd ❑ Hall 9a. RESIDENCE -STATE 91b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER !Including Zip Code) 9e. INSIDE CITY LIMITS 27c. TIME OF DEATH Nebraska Hall Grand Island 604 N. Lambert Yes a No ❑ 11:LlOArn M 10. RACE • (e.g.. White. Black. American Indian. 1 t. CESTRY le.g.. Italian. Mexican, German, etc) t2 ❑MARRIED WIDOWED 13. NAME OF SPOUSE (I/ wile. give maiden name) 28e. On me basis of examination and�Or investigation, in my opinion death occurred al the time, date and place and due to the cause(sl staled. ,,,the etc.I (Specify( White (Specifyt American NEVER DIVORCED Rosalie and TiBe 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? MARRI J. Hout 14a. USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed( o/ working Me, even it retired! Laborer Greenhouse /Refuse Removal Elemema o ee011dary 10.12) College 11 -4 or 5 -1 "1` 16. FATHER . NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME ' • William Perry Thomas I Dessie Otto Scherer 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT -NAME (Yes. no. or unk.) I (it yes. give at and dates of services) 1 Yes: Wq II 2 -1 -1943 12 -18 -1945 Laura Jayne Cole 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( 819 N. Howard, Grand Island, NE. 68803 20. EMBALMER . SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY - NAME NOT EMBALMED ❑Burial ❑Removal 3 -10 -2001 0€nt.ral NE Cremation Servi 22a. FUNERAL HOME - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes Funeral Hom ❑% cremation ❑Donation Gibbon, Nebraska 22b_ FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( 1123 West Second, Grand Island, Nebraska 68801 .23. IMMEDIATE CAUSE . IENTEH ONLY UNE DAUSE PEH LINE 1-UH Is). Ib). AND IC9 i mlerva( between onset and death PART 'Q `/ I ant I quo OX t C_ � FOR VITAL STATISTICS USE ONLY Place.......................A .. ..............................B ..................... NS C ....................................................... ............................... Work...................................................... ............................... UC ........................................................... ............................... Reject................................................... ............................... C................................ D ................................ E ................................ Part II ........................................................................................... ............................... 4 Printed with soy Ink on recycled paper ..........TMV ........................... ............ Census Tract No. ..................... ............................... ............... ............... :e DUE AS A CONSEQUENCE OF I Interval between onset and death �TO, �OR �/1 �y lb) I ' ke�s � C CGLy\ CC(- I DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death I I (c) I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? II (Ages 10.54) Yes No Yes 0 No I Yes D NO 26a. 26b. DATE OF INJURY 1114o.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident ❑ Undetermined M Suicide E] Pending Homicide Investigation ❑❑ 26e. INJURY AT WORK Yes No ❑ 261. PLACE OF IINN,JURY - At hof farm, street. factory O ce build! eta (Specify, 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATH fMa. Day. Yr.) 3116101 �g� 28a. DATE SIGNED /Ma. Day. Yr.l 2 28b. TIME OF DEATH M 27b. DATE SIGNED 1Mo.. Day. Yr.; 27c. TIME OF DEATH 280. PRONOUNCED DEAD 1Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (kourl s - I1010 1 11:LlOArn M N Is M 27d. To the best of my knowletlge. death occurred al the time, date and place and due ro the cause(sl stated. ��.6� 28e. On me basis of examination and�Or investigation, in my opinion death occurred al the time, date and place and due to the cause(sl staled. ,,,the ISi nature and Tide ► • " h./ and TiBe 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.& HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.1b WAS CONSENT GRANTED? 11 YES ❑ NO Z UNKNOWN ❑ YES 9 NO ❑ YES le NO 31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 1 -lea_ her -j. !6cun^aK m,1� 24LILI W. Fa.d 1e ,f ve. Grand siclavid ME 6Wk0 32a. REGISTRAR I 32b. DATE FILED BY REGISTRAR (Ma Day. Yr.) FOR VITAL STATISTICS USE ONLY Place.......................A .. ..............................B ..................... NS C ....................................................... ............................... Work...................................................... ............................... UC ........................................................... ............................... Reject................................................... ............................... C................................ D ................................ E ................................ Part II ........................................................................................... ............................... 4 Printed with soy Ink on recycled paper ..........TMV ........................... ............ Census Tract No. ..................... ............................... ............... ............... :e