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WHEN THIS COPYCAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN_ _S_ERV SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD O THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_.S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUL 12 2001 200107848 ASSISTAAC 9TA TE REG LINCOLN, NEBRASKA HEALTH AND HUMAN SBR� STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE1kVWE$�FA VITAL STATISTICS r CERTIFICATE OF DEATH 1 07423 1F1:EDEN1 -NAME FIRST MIDDLE LAST 2 SEX 3.'DATEOFDEATH IModlh 11,11 1ear1 Hazel Sadie Francis Sidwell Female July 6, 2001 ^ITV AND STATE OF BIRTH Ilt not in USA.. name counlryf Sa AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6, DATE OF BIRTH IMonlh. Day t "earl 5b M05 DAYS Sc HOURS MINS Osceola, Nebraska 'Y's' 87 February 23, 1914 SOCIAL SECURTIV NUMBER ea PLACE OF DEATH 506-12-7711 HOSPITAL ❑ Inpatient OTHER ® Nursing Home ❑ ER Outpatient ❑ Residence So FACILITY Name 111 nol— Nulion, give streel and number] Wed ewood Care Center 1:1 DOA El Other /Spec'ily. . 8c :.11' I UWN OR LOCH LION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island 7� ❑ Hall Yes No 1 go PESIDENCE STATE 9b COUNTY CITY. TOWN OR LOCATION 9d STREET AND NUMBER ilndudng Zip Codol 9e INSIDE CITY LIMITS Nebraska Hall TcGrand Island 1415 N. Cleburn 688011 Yes 10 No ❑ 10 RACE - (eg.. Whne. Black Amencan Indian 11. ANCESTRY leg.. Rehab Mexican. German, etcl t 2 ❑ MARRIED n WIDOWED 11 NAME OF SPOUSE dl wAe give maiden name) tire.] i Specify l White (SPeclly) German NEVER LJ DIVORCED MARRIED Gerald Sidwell 14a USUAL OCCUPATION /Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working life. even Aretiredl Assembl Supervisor Plastic Production Elementa y or Secondary (0 12) College I1 -4 or 8 16 FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME Joseph Hank Myrtle Ransom F 18 WAS DECEASED EVER IN US ARMED FORCES? 'Yes no or unk.) I III yes give war and dates of services) No IlgaINFORMANT-NAME Carolyn Bilslend 19D INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 7617 S. 110 Rd. Wood River NE 68883 20 EMBALMER - SIGNATURE B LICENSE NO 2/a METHOD OF DISPOSITION 1 21 b. DATE 121c CEMETERY OR CREMATORY NAME Not Embalmed F-1 Burial ❑RemovalIJuly 7, 20011 Cent. NE Crem Sery I 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 22a FUNERAL HOME - NAME Apfel Funeral Home ®Cremation ❑Dnnalin Gibbon, Nebraska I CCD `UNtHAI MUMt AUUHI,JJ IJI Httl UH H.F.U. NU.. UI I Y UH I UWN. J1 A I t, LIP( 411 West 11th St. Wood River, Nebraska 68883 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la Ib). AND (U) PART � i A lal DUE TO. OR AS A CONSEQUENCE OF ^ (bl 0� DUE TO OR AS AC\ S OUENNCEE OF Icl C In V 1P V Interval between onset and 1n;1n O Interval between onset and dealli Imer„ai between onset an�i I�•.m OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not relatetl PART In IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART - PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER'/ �b(Ages 10 -54) Yes No Yes F No I& Yes No - 26, 26b DATE OF INJURY (Mo. Day Yr] 26c HOUR OF INJURY 26d. DESCRIBE HOW INJORY OCCURRED 4—dent Undeler ned M �'. Su cide Pending 26e INJURY A7 WORK 261 PLACE OF INJURY - At home. Iarm. street. factory 26q. LOCATION STREET OR R F D. NO CITY OR TOWN STATF Hom,clde Investigation I Yes No ❑ ❑ oftice building, etc /Speedy] 27a DATE OF DEATH (Mo. Day. Yr.) 28a. DATE SIGNED IMo. Day Yr I 28b TIME OF DEATH - - 4 0 27b. DATE SIGNED /MO.. Day vr] 27c TIME OF DEATH 28c PRONOUNCED DEAD /MO Day. Yr) 28d. PRONOUNCED DEAD !Hour) ;awl -7 -7 O 6:00 P M w o M —_ d g z 27d To the best of my knowledge death occ r at the time. date and plate and due to the 28e. On the balls of examination and or investigation, In my opinion death occurred at _ ° causes) stated. ° the time, date and place and due to the causelsl stated. (Signature and Title) ► (Signature and Title 29 DID TOBACCO USE CONTRIBUTE TO TH UTH. 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED? VES ❑ NO ❑ UNKNOWN ❑ YES ® NO ❑ YES ® NO - 3' NAMt ANUAUUHtSSUF UtHIIFILH I PHYSIUTAN. UUHUNtHJ PHY51:MNUH000NIY AT IUHNtYI liypeor —i L.L. Hansen M.D. 3016 W Faidley Grand Island NE 68803 32, REGISTRAR 32b DATE FILED BY REGISTF I_. -. -' -- - - JUL It J W- -/T- V tj