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2 0 Obd 613
<br />_4
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND.HUAfAN SERVICES
<br />SYSTEK IT•CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REQDhD_ WFIL _ -6iff
<br />TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1ST1C§,9MT1dK-_,*`i
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE T.
<br />_ ----- tOOPER'
<br />JUL 5 2000 o 8 9 2 ASSIN_rA�F=T STATE REGISTRAR-:
<br />LINCOLN, NEBRASKA HEALTH AND HU!.4A1f40tV10ES.$yjiTi* ,
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN k-RVTC FINAIW
<br />E'AND-SUP
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH -
<br />MIDDLE LAST SEX 3 DATE 3F DEATH th,.f,, (1,, 1.—
<br />John Gettman Male :June 20,2000
<br />_]N --------
<br />ff�1_11 6 DATE BIRTH 'Month DI, ream
<br />.!I not P U S A.. name Couninvi 7a AGE Last Binhdav � UNDER I YEAR _DA
<br />INS
<br />Adams County,Nebraska tYrs , 83 51b MOS YS ,c i
<br />" - _1� , �� I A L - 1 R T 1 �4 11 fmv 1-1
<br />8b FACILITY Name (It o,,e 11 and number)
<br />Me-s f
<br />Tr TOWN OR I Oi-A Fmi )p DEATH
<br />W-f.
<br />ra RESIDENCE STATE
<br />Nebraska Adams
<br />10 RACE [.g White FlIall, Amen-rilod,an 11 ANCESI
<br />Caucasian _Tla 'jSjTt_C
<br />0 k od ol yo, Jone du,ng most
<br />e,
<br />Farmer-_
<br />A
<br />MIOULI,
<br />-une /_q, jJ-1t) - -----
<br />B. PLACE OF DEATH
<br />HOSPITAL Ij now,en, OTHER Nursing Hom,
<br />F-1 ER Outpatient Res'de"",
<br />DOA Cline, Sn"
<br />80, INSIDE CITY LIMITS I 8,� COUNTY 5F L)EATH
<br />Yes P No Dq I A I _ _ _
<br />� Kenesaw
<br />le q Italian, Mexican. German elcl
<br />12 Y MARRIED
<br />r--j NEVER
<br />14b KIND OF BUSINESS INDUSTRY
<br />Agriculture
<br />LAST _7 7, MnTHFF
<br />Cf;
<br />15150 WEst 76�A5§
<br />t
<br />❑ WIDOWED � 11 NAME 01 SPOUSE W wde Q110 rnald011 1-1)
<br />DIVORCED Leola Kroll
<br />EDUCATION Spec,ly only n guest grace completed)
<br />Efenien(ary of Secondary :0 -t2) Colleqi, I
<br />__L___ - 8
<br />FIRST MIDDLE
<br />man
<br />A Q, INFORMANT NAME
<br />TP W 41 D I IN AhTR FORCES
<br />Y', 'T'., war alo did Wl of
<br />L Leola Gettman.
<br />Tx- 1,
<br />-1(1r!MANI MAIL ING ADDRESS :STREET OR R F D NO CITY OR TOWN SATE ZIPj
<br />_-N-eb raska-68,95-6.
<br />_ __5NA R, LlCrNSE NO DISPOSITION 'Ib OAT� NAME_
<br />k—l"k,wR7At HOME LNAL�F/' Re-va 2nnnirpacordia Ceme-te-r-y-
<br />R5TEI� OR "REMATOP- LOCATION (;ITV )P TOWN STAT�
<br />Dolayv
<br />Jackson- Wilson F.H. I Juniata, Nebraska
<br />l'!*JERAL HOME ADDRESS :STREET OR FLIF () NO CITY OR TOWN. STATE, ZIPJ — - — - — --
<br />N.-Smith Avenue Kenesaw, Nebraska 68956
<br />23 MMEDIA T E CAUSE :ENTER ONLY ONE CAUSE PER LINE FOR lal Rif AND Icl) Interval bhw".ri ousel o
<br />PART
<br />-1 a, Coronary accident Immediate
<br />DUE TO OR AS CONSEOUENCE OF Interval between onset
<br />A
<br />CTHE IT SJUNEICANT CONDITIONS - Conditions contributing to the death but not •elated
<br />PAR,
<br />tI
<br />---T-26-b—DATE OF INJURY JMo Day —1,11 26c HO,,R 01 INJURY
<br />Natural
<br />PART III IF FEMALE WAS THERE A ?I AUTOPSY
<br />PREGNANCY IN THE PAST 3 M-,NTHS'
<br />;Ages 10 541 Yes LJ No Yes R No
<br />1 26d DESCRIBE HOW INJURY OCCURRED
<br />M
<br />26. !NJURY AT WORK 1 261 PLACEOFINJURY Alnome fa,,m sveel factory 126g LOCATION
<br />tf-oe building, etc ��c,fyl
<br />HI-cc;7 11—t9aWn 1 Yes No F]
<br />2;T 'F DEATH Mo Day Y, I
<br />5 71 -)AIF SIGNED /Vo Day Y, 127c TIME OF DEATH
<br />M
<br />271 T:; -3eS( ol;nV knowledge ioath or,--o at the time dale and olace and d:, t-
<br />118kid
<br />5"••,re and Tide)
<br />STREET OR FTr D NO
<br />28a DATE SIGNEC IMo Day Yr)
<br />June 28, 2000
<br />2 28r, PRONOUNCED DEAD IMP Day, Yr!
<br />I
<br />-: -,June 20. 2000
<br />liw1_111 between tinsel 1 'e
<br />WAS (-,A-,F REFCRRF[7-O
<br />EXAMINER OR CORONr1�
<br />Yes _;LI - L
<br />C11YORTOWN
<br />g8l) TIME OFDEATIR-
<br />11:30 a ti
<br />28d PRONOUNCED DEAD
<br />1:10 p
<br />6 1 28e Or, the basis of examinalkan and Or Investigation. in my opin,-
<br />Toe time date and o1a,o and due to 1.
<br />ISrdnature and Title 1^111"
<br />31 NAME AND ADDRESS OF l.it9TIRER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY, (Type or P,,ntj
<br />Meredith Oakes Peterson, Dpputy County Attorney P.O. Box 71, '11astings, NE 68901
<br />32a REGISTRAR 17 1 32b DATE FILED BY REGISTRAR (Mo.. Day, Y,)
<br />JUL 2000
<br />11 V
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