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M C1 !l
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Yearl
<br />Rosie Marie Why to
<br />Female I
<br />r) D<
<br />4. CITY AND STATE OF BIRTH O not rr U S A.. rlarne cauntryl
<br />Sa. AGE -Last Birthday
<br />UNDER i YEAR
<br />cu
<br />a 7C
<br />TTT R
<br />s
<br />C
<br />z
<br />M
<br />Tv
<br />CU
<br />October 15, 1929
<br />I 7 SOCIAL SECURTIY NUMBER
<br />_
<br />Be. PLACE OF DEATH -
<br />508 -30 -4608
<br />076.
<br />r i 4,
<br />C� f 1
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<br />'Tt
<br />O
<br />1-4
<br />Ch
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<br />bq O •' !! ! C� M C..
<br />'U
<br />A U3
<br />O
<br />C10
<br />t-- M
<br />G v,
<br />N
<br />13
<br />-�
<br />rr-
<br />U)
<br />;K
<br />O
<br />�S
<br />O .
<br />O
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY le g.. Italian. Mexican. German, etcl
<br />cu
<br />13. NAME OF SPOUSE tlf wife. give maiden name)
<br />etc.) lSceclfyl
<br />White
<br />(Specify)
<br />Polish
<br />NEVER DIVORCED
<br />R
<br />John T. Wh Whyte, JR.
<br />Y
<br />�
<br />14b. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed)
<br />of working life. even it rearedl
<br />Homemaker
<br />Elementary or Secondary 10 -121 College ( 1 -4 or 5.1
<br />Domestic 12th Grade
<br />m
<br />Lot Nine (9) in Block Eighteen (18) in Schimmer's Addition to
<br />the City
<br />of
<br />28 1999
<br />Grand Island, Hall County, Nebraska.
<br />N�€
<br />E
<br />ctober
<br />• M
<br />0 4
<br />g
<br />M
<br />27d. To the best of my knowledge. death w.curred at the and due to Ih0
<br />2Be. On the basis of exammatgn antl,or investigation, in my opinion death occurred at
<br />3
<br />MEN THOS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL 04 AND HIAMAN SERVICES
<br />=te
<br />causelsl stated. '`
<br />��
<br />a
<br />the time, date and pace and due to the causes) stated.
<br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R -0AI JNTH
<br />Sionatwe and Tills �
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HA ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />THE NEBRASKA HEALTH AND' HUMAN SERVICES SYSTEM, VITAL STATISS)Til11f,lS'
<br />YES 1:1 NO ❑ UNKNOWN
<br />1:1 YES O
<br />❑ YES ❑ NO
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ =
<br />DATE OF ISSUANCE
<br />200107674
<br />NOV 10 1999
<br />AS$STivT s'^rAITFhst
<br />LINCOLN, NEBRASKA HEALTH AND Ak4i N SERVICES SV*TW
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEk FrCFS-MANCE A$S3 SUPPORT
<br />VITAL STATISTICS -
<br />CFRTTF1('.ATF CIF T)FATM
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Yearl
<br />Rosie Marie Why to
<br />Female I
<br />October 28 199
<br />4. CITY AND STATE OF BIRTH O not rr U S A.. rlarne cauntryl
<br />Sa. AGE -Last Birthday
<br />UNDER i YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day Year)
<br />Sb. MOS, DAYS
<br />Sc. HOURS MINS
<br />a
<br />Nance County, Nebraska
<br />)Vrs.l
<br />70
<br />October 15, 1929
<br />I 7 SOCIAL SECURTIY NUMBER
<br />_
<br />Be. PLACE OF DEATH -
<br />508 -30 -4608
<br />HOSPITAL: 0 Inpatient OTHER: ❑ Nursing Home
<br />- -- -
<br />❑ ER Outpatient ❑ Residence
<br />( BD FACILITY - Name (a no nslitNtoa, give sheet and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ otherl8pecdy
<br />i 8c. CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes n Nd ❑ Hall
<br />a n�SwENOc- SFATe --
<br />- GVyCtY-- -- . -- ---
<br />.t3fTi':-i6WthtiRtriEntiOry -- -`
<br />ba- 5iirt :21- ArvtrtvdMEtti•�rmcludarg Yip clods / - - '9e INSIDE CITY UmuS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />408 W. 16th St. 68801 Yea No ❑
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY le g.. Italian. Mexican. German, etcl
<br />t 2. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE tlf wife. give maiden name)
<br />etc.) lSceclfyl
<br />White
<br />(Specify)
<br />Polish
<br />NEVER DIVORCED
<br />R
<br />John T. Wh Whyte, JR.
<br />Y
<br />14. USUAL OCCUPATION /Give kindof wwh done during most
<br />14b. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed)
<br />of working life. even it rearedl
<br />Homemaker
<br />Elementary or Secondary 10 -121 College ( 1 -4 or 5.1
<br />Domestic 12th Grade
<br />_ Frank NMN _ Kiolbasa Barbara
<br />18 WAS DECEASED EVER It' L'S AgMED FORCES' 19a. INFORMANT � NAME
<br />)Yes. no. or unk.l I III ves give w and dates of services)
<br />No • - - - - -- John T. Whyte,
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />408 W. 16th St., Grand Island, Nebraska 68801
<br />'0 E f R
<br />MIUULL MAIUEN SUHNAME
<br />Uz
<br />-SIGN T tom_ K NSE NO 218. METHOD OF :I
<br />DISPOSPION 21b DATE C U0ALTERY OR CRE'AATORYI'IAME
<br />/// Burial ❑Removal Nov. 1, 1999 Grand Islan3 City Cemetery
<br />22a Fl1NERA O - NAME 121d. CEMETERY OR:,REMATORY LOCATION CIT'! OR TOWN STATE
<br />Livingston- Sondermann F.H. ❑CramaW 0 0r -1- Grand Island, Nebraska
<br />22b. FUNERAL HCME AD.' _[ -S !STREET OR R.F.D NO.. CITY OR TOWN. STATE, BPI
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE )ENTER ONLY ON AUSE PER E FOR lal. (b). AND (c)1 .Interval Delwce rise( and death
<br />PART
<br />DUE TO, OR AS A CONSr LIENGE 0 Int val between ci s et and death
<br />DET6DRAS7C'OORSEOOE2ECF:- l -- - -1-1 - -- - - --- - •� CK
<br />InMrval I �Meen onset _a.d,10, m -
<br />1 kl r. C C.
<br />OTHER SIGNIF ANT CONDITIONS - Conditions coma rig It the death but elate PART
<br />PART - PREGNANCY
<br />11\}
<br />III IF FEMALE. AS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24 .AUTOPSY
<br />25 WAS CASE REFERR TO MEDICAL
<br />EXAMINER OR CORD H
<br />It
<br />.` C1 -• 11
<br />�4
<br />``•' JI j t� �V`
<br />10 -54) Yes No
<br />Yes- No
<br />Yes R No
<br />26a
<br />26b DjrE OF INJURY fhlo.. Day. Yr.)
<br />26c. HOUR OF INJURY1
<br />26d. DESCRIBE HOW INJURY OCCU ED
<br />Accident Undelermmad
<br />M
<br />Smelde Pending -
<br />26e. INJURY AT WORK
<br />26f. PLAeCE Fi INJURY - At home, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />HomrCide- InvesLgalion
<br />Yes No
<br />❑ ❑
<br />offM1M1 bu nt , ispec'ty)
<br />1
<br />,
<br />27a. DATE OF DEATH (Mo.. Day. Yr)
<br />28a, DATE SIGNED /MO. Day Yr I
<br />28b TIME OF DEATH
<br />October 28 1999
<br />A
<br />M
<br />N
<br />i�
<br />g t
<br />n <
<br />27b. DATE SIGNED tMo.. Day Yr/
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day, Yr)
<br />28d. PRONOUNCED DEAD /Hour)
<br />°
<br />28 1999
<br />N�€
<br />E
<br />ctober
<br />• M
<br />0 4
<br />g
<br />M
<br />27d. To the best of my knowledge. death w.curred at the and due to Ih0
<br />2Be. On the basis of exammatgn antl,or investigation, in my opinion death occurred at
<br />3
<br />=te
<br />causelsl stated. '`
<br />��
<br />a
<br />the time, date and pace and due to the causes) stated.
<br />1�' ( -
<br />ISI nalwe antl Title �+
<br />Sionatwe and Tills �
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HA ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES 1:1 NO ❑ UNKNOWN
<br />1:1 YES O
<br />❑ YES ❑ NO
<br />...,......" ............. w�.,,., �..,,..�.,I�...„o,,.,n.wrnn.c..a rr.ran,v.n v.. r,wmrnrlvnnca Irypwrnm,
<br />William J Landis, 2444 jj� Faidley, Grand Island, NE 68803
<br />32a. REGISTRAR _ - ff NW I 32h DATE Fit Fn RV t (- ICTRAR ilii /Lv yr 1
<br />
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