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<br />5a. AGE - Last Birthday
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<br />6, DATE OF BIRTH IMonth. Dav Year;
<br />Giltner, Nebraska
<br />" 119 5b
<br />Nov. 1 9, 1 91 1
<br />M0S l DAYS
<br />5c. HOURS MINS
<br />T, SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH
<br />507-62-0283 HOSPITAL ❑ Inpatient OTHER ® Nursing Home
<br />8b. FACILITY - Name (If not mshfution, give street and number/ ❑ ER Outpatient ❑ Residence
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIMAIx
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA'1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200107516
<br />- =-
<br />MAR 8 2001 ARSMTj
<br />LINCOLN, NEBRASKA HEALTH ANI' ALA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN "ER
<br />SERVICES
<br />FJLE *17H -
<br />iVQJWCE AND SUPPORT
<br />CERTIFICATE OF DEATH =- __- 01 01803
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<br />2. SEX - -'
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<br />4. CITY AND STATE OF BIRTH (ffnain USA.. name country;
<br />5a. AGE - Last Birthday
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<br />6, DATE OF BIRTH IMonth. Dav Year;
<br />Giltner, Nebraska
<br />" 119 5b
<br />Nov. 1 9, 1 91 1
<br />M0S l DAYS
<br />5c. HOURS MINS
<br />T, SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH
<br />507-62-0283 HOSPITAL ❑ Inpatient OTHER ® Nursing Home
<br />8b. FACILITY - Name (If not mshfution, give street and number/ ❑ ER Outpatient ❑ Residence
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<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code; 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Adams
<br />r�
<br />3707 S. 90th Rd. 68883 Yes No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g. Italian. Mexican. German, etc)
<br />t2 .A MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Of wife give maiden name)
<br />l.!
<br />(Speofy)
<br />American
<br />Z M
<br />Hazel G . Robinson
<br />--e
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working file. even if retired)
<br />Elementary or Secondary 10 12) College I -4 or 5.1
<br />Homemaker
<br />Self
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />AIR N
<br />Ida Edna Gannon
<br />r m
<br />-J
<br />cc►
<br />cn
<br />No
<br />Bart Robinson
<br />cn
<br />13150 Reay Avenue Prosser, Nebraska 68868
<br />20.E R- SIGNATURES UCENS NO
<br />21 a. METHOOOF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />,'
<br />f�.
<br />>4 Burial ❑Removal
<br />Feb. 1 2, 2001
<br />Rosedale Cemetery
<br />22 . CNERAL-16ME - NAM&
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Jackson - Wilson F.H.
<br />❑Draml ❑°°Doti°"
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<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />209 N. Smith Avenue Kenesaw, Nebraska 68956 _
<br />23. IMMEDIATE USE c (ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (cll Interval between onset ono neat,
<br />PART
<br />I
<br />la) AA
<br />64
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIMAIx
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA'1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200107516
<br />- =-
<br />MAR 8 2001 ARSMTj
<br />LINCOLN, NEBRASKA HEALTH ANI' ALA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN "ER
<br />SERVICES
<br />FJLE *17H -
<br />iVQJWCE AND SUPPORT
<br />CERTIFICATE OF DEATH =- __- 01 01803
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX - -'
<br />3. DATE OF DEATH /Month. Dav Year;
<br />Feb. 07,2001
<br />4. CITY AND STATE OF BIRTH (ffnain USA.. name country;
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />U
<br />6, DATE OF BIRTH IMonth. Dav Year;
<br />Giltner, Nebraska
<br />" 119 5b
<br />Nov. 1 9, 1 91 1
<br />M0S l DAYS
<br />5c. HOURS MINS
<br />T, SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH
<br />507-62-0283 HOSPITAL ❑ Inpatient OTHER ® Nursing Home
<br />8b. FACILITY - Name (If not mshfution, give street and number/ ❑ ER Outpatient ❑ Residence
<br />Haven Home Qf Ke_ nesaw ❑ DOA ❑ Other(Specityl
<br />8c. CITY. TOWPTORCOCATION OF DtA i n 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Kenesa_ w Yes -� Np ❑ Adams
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code; 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Adams
<br />Prosser
<br />3707 S. 90th Rd. 68883 Yes No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g. Italian. Mexican. German, etc)
<br />t2 .A MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Of wife give maiden name)
<br />etc.) ISoe fyl
<br />Caucasian
<br />(Speofy)
<br />American
<br />NEVER DIVORCED
<br />MRI
<br />Hazel G . Robinson
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working file. even if retired)
<br />Elementary or Secondary 10 12) College I -4 or 5.1
<br />Homemaker
<br />Self
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />AIR N
<br />Ida Edna Gannon
<br />18. WAS DECEASED EVER IN U.S. ARM FORCES?
<br />79a. INFORMANT -NAME
<br />IYes no. or unk.l 11f yes. give war and dates of servicesl
<br />No
<br />Bart Robinson
<br />19b. INFORMANT MAILING ADDRESS fSTREET OR R.F.D NO.. CITY OR TOWN. STATE. ZIP)
<br />13150 Reay Avenue Prosser, Nebraska 68868
<br />20.E R- SIGNATURES UCENS NO
<br />21 a. METHOOOF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />,'
<br />f�.
<br />>4 Burial ❑Removal
<br />Feb. 1 2, 2001
<br />Rosedale Cemetery
<br />22 . CNERAL-16ME - NAM&
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Jackson - Wilson F.H.
<br />❑Draml ❑°°Doti°"
<br />Rosedale, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />209 N. Smith Avenue Kenesaw, Nebraska 68956 _
<br />23. IMMEDIATE USE c (ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (cll Interval between onset ono neat,
<br />PART
<br />I
<br />la) AA
<br />DUE TO, 6R CONSEQUENCE OF Interval betwel onset and death
<br />DUE TO. OR AS A CONSEQUENCE OF Inter een onset and Beam
<br />lot
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONERS
<br />II
<br />- (Ages
<br />10 -541 Yes No
<br />VB5 No
<br />Yes NO
<br />26a.
<br />26b DATE OF INJURY (MO.. Day. Yr)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY URRED
<br />Accident � Undetermined
<br />M
<br />Suicide [_� Pending
<br />26e. INJURY AT WORK
<br />26f J�URY %A� homp, farm, street. factory
<br />buOFiIN
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />EJ Homicide Investigation
<br />❑
<br />oPLAe
<br />t c
<br />6 f)y
<br />Yes NO
<br />27a. DATE OF DEATH /MO. Day Yr.)
<br />28a. DATE SIGNED (M... Day Yr.)
<br />28b TIME OF DEATH
<br />�<
<br />February 07 2001
<br />�
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<br />uy1
<br />27b DATE SIGNED /MO. Day. 1,Y)
<br />27c. TIME OF DEATH
<br />,
<br />0 < y
<br />28c. PRONOUNCED DEAD /Mo. Day, Yr.)
<br />2Bd. PRONOUNCED DEAD (Hour;
<br />8
<br />Februar 001
<br />11 :40.P.M.M
<br />s � =�
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<br />27d. To dte best y de occurred he time, date and place and due to me
<br />2 o6 28e. On the basis of examination and or investigation, in my opinion death oecurretl a1
<br />causels) sta
<br />° a ► the time, date and place and due to the cause(s) stated.
<br />(Signature a �Z.
<br />IS nature and Title
<br />29. DID TOBACCO USE TRI U O EA H? 30.a
<br />HAS ORGAN OR TISSUE DONATION CONSIDERED? 30.b
<br />WAS CONSENT GRANTED'
<br />•NO
<br />❑ YES NO UNKNOWN
<br />❑ YES
<br />5N.
<br />❑ YES
<br />31. iJAE1E AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type a Pri fl
<br />'William F wl s MD-716 Alpha
<br />_32a.1 AE TR
<br />32b. DATE FILED BY REGISTRAR (Mp.. Day Yr/
<br />,
<br />IwAft -Aber-
<br />rre-r% " A 0 ^AAA
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