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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM N498 /ICES SYSTEIK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECDOD WAX -F-MTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSMC TWX WHOW THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF IS U N ll.L & 000PER AL l t l� 01 200107205 ASs;s;;A flrsrArEREGISTAAR= LINCOLN, NEBRASKA HEALTH AND HWANSERV7CES SYSTElY1 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERvicES EINAN sUIVORT VITAL STATISTICS = -- _ = 01 07303 CERTIFICATE OF DEATH Ca 01, A -C Q O 'rt "1r) xr" r *I. 1 DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH ;Monrn Day Yaarl Norman Eugene m T male; July 1, 2001 n > 5a. AGE - Last Birthday 0 UNDER t DAY © = D Z Yrsl 66 Oct. 19, 1934 r) _ Fill � re- / $ i P npauent OTHER ❑ Nursing Home 508 -40 -1731 27c TIME OF DEATH HOSPITAL 28d. PRONOUNCED DEAD /HuU J a �, ❑ ER Outpatient ❑ Residence Bb. FACILITY -Name (If not institution, give street and number) St. Elizabeth Hospital M N N 8d INSIDE CITY LIMITS Be COUNTY OF DEATH - Lincoln 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES VI No ❑ UNKNOWN N W 30.b WAS CONSENT GRANTED' ❑ YES erNO �C 9a. RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9tl STREET AND NUMBER /Including Zip Codel 9 v LIMITS Nebr. Hall m W � Yes ® No ❑ 10. RACE - leg, While. Black American Indian 11. ANCESTRY le g Italian, Mexican, German, etc) 12. ❑ MARRIED ❑ WIDOWED 13 NAME OF SPOUSE of w,fe give maiden camel etc .I ISI ite A rn 3 DIVORCED MARRI 14a. USUAL OCCUPATION (Grve kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION r` Elem ary or Secondary (0 -12) College I1 .4 or i- I of workr life even it reined) Farmer Agriculture (n ca LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Louis Skeen Evelyn Stairs 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 79a. INFORMANT - NAME - )Yes. no or unk.) I d/ yes give war and date$ of services) yes not of record INC Gerald Skeen -� Z O Lj WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM N498 /ICES SYSTEIK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECDOD WAX -F-MTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSMC TWX WHOW THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF IS U N ll.L & 000PER AL l t l� 01 200107205 ASs;s;;A flrsrArEREGISTAAR= LINCOLN, NEBRASKA HEALTH AND HWANSERV7CES SYSTElY1 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERvicES EINAN sUIVORT VITAL STATISTICS = -- _ = 01 07303 CERTIFICATE OF DEATH Ca 01, A -C Q O 'rt "1r) xr" r *I. 1 DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH ;Monrn Day Yaarl Norman Eugene Skeen male; July 1, 2001 4. CITY AND STATE OF BIRTH lit not to USA. name country) Accident Undetermined 5a. AGE - Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH )Month. Day Year) 5b MQS l DAYS Sc HOURS MINS Shelton, Ne. Yrsl 66 Oct. 19, 1934 7. SOCIAL SECURTIY NUMBER 28a DATE SIGNED rMo Day. YrI 8a PLACE OF DEATH y / $ i P npauent OTHER ❑ Nursing Home 508 -40 -1731 27c TIME OF DEATH HOSPITAL 28d. PRONOUNCED DEAD /HuU J a I ❑ ER Outpatient ❑ Residence Bb. FACILITY -Name (If not institution, give street and number) St. Elizabeth Hospital A ❑ DOA ❑ Other)Specty _.- 8e. CITY. TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH - Lincoln 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES VI No ❑ UNKNOWN Yes 50 No ❑ 30.b WAS CONSENT GRANTED' ❑ YES erNO Lancaster 9a. RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9tl STREET AND NUMBER /Including Zip Codel 9 v LIMITS Nebr. Hall Grand Island 804 No. Boggs Yes ® No ❑ 10. RACE - leg, While. Black American Indian 11. ANCESTRY le g Italian, Mexican, German, etc) 12. ❑ MARRIED ❑ WIDOWED 13 NAME OF SPOUSE of w,fe give maiden camel etc .I ISI ite A (Specify) American I EVER ®N DIVORCED MARRI 14a. USUAL OCCUPATION (Grve kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specfy only nrghesl grade completed) _ Elem ary or Secondary (0 -12) College I1 .4 or i- I of workr life even it reined) Farmer Agriculture 16. FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Louis Skeen Evelyn Stairs 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 79a. INFORMANT - NAME - )Yes. no or unk.) I d/ yes give war and date$ of services) yes not of record Gerald Skeen 19b. INFUHMAN I MAILINU AUUHtJJ 1J I H I VH - . u. - - r - r v vn n r r_, u` P.O. Box 311 Wood River, Ne. 68883 20. EMBALMER - SIGNATURE 8 LICENSE NO 21 a. METHOD OF DISPOSITION 21b. DATE not embalmed ❑ Burial ❑ Removal 7 -5 -01 22a. FUNERALHOME NAME 21d. CEI, Apfel Funeral Home ®Carnation ❑Dori 221. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 411 W. 11th St. Wood River, Ne. 68883 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal Ib). PART (al Yom, ' V / •� DUE TO, OR AS A CONSEQUENCE OF - c CEMETERY OR CREMATORY NAME B.M.L. Cremation Service TION CITY OR TOWN STATE Lincoln, Ne. 11MI Interval between onset and n�, -I•, Interval between onset and heat, DUE TO. AS A CONSEQUENCE OFA / -/ Interval between onset and dean - 5 T .t ✓ Q 4..A ;Ki OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but elated PART PART n / PREGNANCY C „ III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS' (Ages 10 -54) Yes No 24 AUTOPSY yes Na 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER' Yes No 26a 26b. DATE OF INJURY (MO.. Day YrJ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined 1 M ❑ Suicide M Pending Homicide investigation ❑❑ 26e. INJURY AT WORK yes No ❑ 261. PLACE QF INJURY - At home. farm. street. factory 08 ce budding. etc. ISper, 26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a DATE OF DEATH /MO.. Day YrI 28a DATE SIGNED rMo Day. YrI 28b TIME OF DEATH y / $ i P M 27b DATE SIGNED (Mo.. Day. Yrl 27c TIME OF DEATH 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD /HuU J a I /G 0 Q M } z� �° O A 27d To the best of my knowledge. th occ ed at It , date a Ce due IO the cause(s) slated. 28e. On the basis or examination and or investigation, in my opinion Beam occurred at the time, date and place and due to the causelsl stated. (Si nature and Tide) ► (Signature and Tale) ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES VI No ❑ UNKNOWN 30.a HAS ORGAN OR TISSU ONATION BEEN CONSIDERED' YES NO 30.b WAS CONSENT GRANTED' ❑ YES erNO 31. NAME AND ADDRESS OIF`- CERTIFIER [PHYSICIAN. CORONER'S PHYSICIAN OR C7PNT6 ATTORNEY( /Type a Print/ Dr. Thomas Stalder 1500 Sojf.S8 Lincoln, Ne. 68506 321 REGISTRAR /1w , _ O^ ,..r te'\ 32D DATE FILED BVIREGISTRC l )mi Yr.1 O N ri O .�+. O CD O CIO tG. n N O � en co Z R� n uJ � N V � N\ c) V RI M o n C Vv `: