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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND k SYSTEM, IT CERT)FIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIG�a`$P THE LEGAL DEPOSITORY FOR VITAL RECORDS - DATE OF ISSUANCE l JUN 101997 200106888 ASSISTIFfei UNCOLK NEBRASKA _ -__ -- -- -- HEALTH AND HUM& B! STATE OF NEBRASKA - DEPARTMENT OF HEAD BUREAU OF VITAL STATISTICS CERTIFICATE OF DEATH WS; COOK E REOtMAR 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH µMont. pay. Year) Lillie Emma Gerdes Female I June 03, 1997 1. CITY AND STATE OF BIRTH (tend h U.S.A. name cloraey) Se. AGE - Lad BiNWay I UNDER 1 YEAR UNDER 1 DAY 16. DATE OF BIRTH fiMorah. Day. Year) Phillips, Nebraska 90 5b. Mos. I DAYS sd.liOURS; MINE. Jul 23, 1906 7. SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH 507 -42 -4317 HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home ❑ ER Outpatient ❑ Residence �. Bb. FACILITY - Name (Knot irlsiltua4 give street and numbed Tiffany Square Care Center - - - ❑ -DOA -- - ❑ od ar t Bc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CRY LIMITS So. COUNTY OF DEATH Grand Island Yes [g No ❑ Hall I 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including2o Cade) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 3119 W. Faidley Ave., 68803 Yea ❑X Nb ❑ 10. RACE - le.g.. White. Black. American Indian. 11. ANCESTRY le.g.. Italian, Mexican, Gersten. Net 12. MARRIED ❑WIDOWED 13. NAME OF SPOUSE td wile, give maiden name) el iel I American NEVER DIVORCED I Marvin Gerdes 14a. USUAL OCCUPATION (Give kind of wndr donne doing motel 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only Ngletlt grade completed) Elementary or Secondary 10 -121 (1 -4 or 5 -I of working Ise, even it rearedl 1 Teacher Education 12 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Axel Fredrickson Ma Anderson 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.) Id yes, give war and dates of services) No Marvin Gerdes 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 717 West John, Grand Island, Nebraska 68801 20. EMBALMER - S E/8 LLIIC/ENNSSE,NO� 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY - NAME /IGNATU �7y #122 n Burial ❑ Ramd�al June 6 1997 Grand Island City Cemetery a. FUNE RAL HOME - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes Funeral Home ❑.gin ❑ Donshoh Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 23. PART IMMEDIATE CAUSE (//p / (ENTER Y ONE CAUSE PER LINE FOR Ian. (b). AND (c)) Interval between onset and death IaI ` ✓ U 4* a DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death I I (bl DUE TO, OR AS A CONSEQUENCE OF: - - t k'.0N W between onset and death I I (c) OTHER SIGNIFICANT CONDITIONS - Condihons conl'ibulirlp to the death but not related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Ages 10 -541 Yes No Val No Yes No 26a. 28b. DATE OF INJURY /M0.. Day. Yr.) 26c. HOUR OF INJURY DESCRIBE MOW INJURY OCCURRED Accost F1 Undetermined 126d. / M F-1 Suicide ❑ Pending 26e. INJURY AT WORK 2% PLAB E fJF INJURY %N hogs, fam. sheet. factory o1RRte fHa101^F SPeaal'/ 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE H. -Cide Invedgabon Yes ❑ tea ❑ 1 27a. DATE OF DEATH (W... Day. Yr.) 28a. DATE SIGNED (AMo. Day. Yr.) 28b. TIME OF DEATH June 3, 1997 M a< a 27b. DATE SIGNED (MO.. Day. Yr.) 27e. TIME OF DEATH 28c. PRONOUNCED DEAD (Ale.. Day, YrJ 28d. PRONOUNCED DEAD (Hour) k T June 3, 1997 5:34 a. M HIS st M �R 27d. To She best of my knowledge. de&M occur It the time, dale and place and due to the 26e. On she basis of examination and /or' n opinion death occurred at as cause(sl slated. , /. c / (:�. u a the time. dab and place and due b this Stated. - ( nature and Title V /W, (Signature and Tide 29. DID TOBACCO USE CONTRIBUTE T THE DEATH. 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES NO 11 UNKNOWN 1:1 YES al-146 ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or PNnt) Dr. A.E. Van Wie, 108 N. Howar Ave., Grand Island, Nebraska 68803 32a. REGISTRAR if 6MV6.b. 32b. DATE FILED aTRARdAI/rllyly A F Exhibit "A"