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<br />The Easterly Eighty -Five Feet (85') of Lot Nineteen (19), except
<br />the Easterly Seventeen Feet (17') thereof, in Block Five (5), in
<br />Wester7hoff's First Subdivision in the City of Grand Island, Hall
<br />Country, Nebraska, except the Southerly :'.;irty Feet (30') thereof
<br />deeded to the City of Grand Island, for street purposes.
<br />.J
<br />CD -i
<br />C:D
<br />rn
<br />Male 'I'May
<br />21, 2000
<br />i CITY AND STATE OF BIRTH iunotin USA. name country)
<br />t
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH iMonth. Dav Year)
<br />MOS DAYS
<br />5c HOURS MINS
<br />1771
<br />(Yrs Sh
<br />Co
<br />Shelton, Nebraska
<br />88
<br />tr
<br />January 8 1912
<br />Ca z;
<br />O
<br />N
<br />HOSPITAL ❑Inpatient OTHER © N., —,H °me
<br />❑ ER Outpatient ❑ Residence
<br />Bb FACILITY - Name /Nnot,nstitutiort. give street and number/
<br />Western Hall Co. Good Samaritan Center
<br />❑ DOA ❑ Other - --
<br />=.
<br />r
<br />Wood River ___ Yes_ ® Nn ❑
<br />Hall
<br />9a RESIDENCE STATE
<br />r°
<br />9e CITY. TOWN OR LOCATION
<br />9tl STREET AND NUMBER dncludmq LO Ccxfel T 9e INSIDE CITY'. i1uT
<br />►-�
<br />c, -
<br />cv
<br />3016 West 16th YPS� N, ❑
<br />F—
<br />x
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE lit wde grve ma,den name)
<br />etc ll SO—NI Whi to
<br />D
<br />NEVER DIVORCED
<br />Pauline Myrtle Richards
<br />I.-A
<br />vv
<br />MARRIED
<br />N
<br />N
<br />W
<br />Elementary or Secondary 10 121 College a '
<br />Farmer
<br />Cn
<br />16 FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST NAME
<br />MIDDLE MAIDEN SURNAME
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND_MIWAff SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REOPRO Q Jkk1 fH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC3.SECTIOA4 W mfis
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 2 ( LZ _
<br />0 =�
<br />2 U 0 0 8
<br />nn
<br />JUN 82000 A SSIStANT.STA TE REG1,SMAItf
<br />LINCOLN, NEBRASTA7 OF NEBRASKA- DEPARTMENT OF HEALTH ALNDHFNINNADN SEERR3_;AIC� s -_t tNn A p ST RT
<br />VITAL STATISTICS _-
<br />CERTIFICATE OF DEATH
<br />�.So
<br />IiDEDECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />-3 DATE OF DEATH ,41owh Day year
<br />Floyd Harvey Finck
<br />Male 'I'May
<br />21, 2000
<br />i CITY AND STATE OF BIRTH iunotin USA. name country)
<br />Sa. AGE Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH iMonth. Dav Year)
<br />MOS DAYS
<br />5c HOURS MINS
<br />(Yrs Sh
<br />Shelton, Nebraska
<br />88
<br />January 8 1912
<br />7 SOCIAL SECURITY NUMBER
<br />Ba PLACE OF DEATH
<br />506 -16 -8821
<br />HOSPITAL ❑Inpatient OTHER © N., —,H °me
<br />❑ ER Outpatient ❑ Residence
<br />Bb FACILITY - Name /Nnot,nstitutiort. give street and number/
<br />Western Hall Co. Good Samaritan Center
<br />❑ DOA ❑ Other - --
<br />8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Wood River ___ Yes_ ® Nn ❑
<br />Hall
<br />9a RESIDENCE STATE
<br />9b. COUNTY
<br />9e CITY. TOWN OR LOCATION
<br />9tl STREET AND NUMBER dncludmq LO Ccxfel T 9e INSIDE CITY'. i1uT
<br />Nebraska
<br />Hall
<br />Grand Island
<br />3016 West 16th YPS� N, ❑
<br />10 RACE - (e.g. White. Black Amencan Indian.
<br />11 ANCESTRY le g.. Italian. Merman. German. etcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE lit wde grve ma,den name)
<br />etc ll SO—NI Whi to
<br />Spec
<br />Berman
<br />NEVER DIVORCED
<br />Pauline Myrtle Richards
<br />MARRIED
<br />14a. USUAL OCCUPATION iGrve kind of work done during most 146
<br />KIND OF BUSINESS INDUSTRY 15 EDUCATION Speoly only highest grade c ,npleteal
<br />of wwA nq hie. even d retried)
<br />Elementary or Secondary 10 121 College a '
<br />Farmer
<br />Agriculture 12
<br />— — - --
<br />16 FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST NAME
<br />MIDDLE MAIDEN SURNAME
<br />John Casper Finck
<br />Leda Dora Fines
<br />18 WAS DECEASED EVER IN US ARMED FORCESv
<br />19a INFORMANT - NAME
<br />(Yes. �e O, unkl I 111 yes qwe war and dates 01 SBrvmeS)
<br />No
<br />Pauline Finck
<br />19b INFORMANT MAILING ADDRESS ISTRFET OR R.F D NO. CITY OR TOWN STATE ZIP)
<br />301_6 West 16th GraDd Isla d NE 68801 _
<br />20 B ER- SIGNATUR ENO. 1 /
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<br />21a METHOD OF DISPOSITION
<br />' DT ATE tic CEMETERVOR CREMATIWI NAME
<br />�f J
<br />X Burial Removal
<br />❑ ❑
<br />5/24/2000 Riverside Cem_e_te_ry____--
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a F UN RA OME NAME
<br />Ap el Funeral Home
<br />1:1 Cremation ❑ Opna "°
<br />Gibbon NE
<br />22b. FUNERAL HOME ADDRESS ISTREET OR RED. NO CITY OR TOWN STATE, ZIP)
<br />411 West 11th P.O. Box 126 Wood River NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (c)l Interval between onset 1,. ...,
<br />PART
<br />1A Metastatic Cholangiocarcinoma. Approx 6 month_
<br />'
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset an I nea,^
<br />(b) N/A
<br />-- — - - -- -- _ - — — -
<br />DUF TO OR AS A CONSEQUENCE R� t,,
<br />_JENCE OF liS' ITD II Diabetes ,-
<br />�1ype
<br />Right Renal Mass.
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />5 WAS CASE REFEP,Rt D T,) MEDICAI
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS'
<br />EXAMINER OR CORONIIr
<br />(Ages
<br />10-54) Yes NO
<br />Yes NO
<br />26a
<br />26b DATE OF INJURY (Me Day. Yrl
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY r`:'�i IRRED
<br />A—denl J Undeannihad
<br />M
<br />Su,c,de E] Pend,nq
<br />26e INJURY AT WORK 261 PLLACE OF INJURY - At home la .m street factory
<br />26g LOCATION STREET OR R.F D. NO .:I1 r OR TD,',N
<br />rEl
<br />Homicide Investigation
<br />❑ ❑ 0Hlce building, all 'Spec,lyi
<br />u
<br />YBS N°
<br />27a DATE OF DEATH /Mo.. Day YrI
<br />28a DATE SIGNED (Mo. Day. TY)
<br />28b TIME OF DEATH
<br />o<
<br />5 -21 -2000
<br />r<w
<br />V
<br />yr
<br />a Y
<br />27b. DATE SIGNED /Mo.. Day. Yrl 27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day, YrI 280. PRONOUNCEU DEAD 'Ro,
<br />g
<br />6 -01 -2000 �i�, aM
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<br />27d To me best of nowledge. occurYdel IT da and place and due to me
<br />~ <
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<br />28e. On the basis o1 exarnhauon and or Investigation, in my oplmon dew- ate,. urreo AT
<br />ca.Zsl stated.
<br />MN
<br />° S
<br />the time, dale and place and due to the causelsl stated.
<br />10., nature and Tltle ►
<br />ISM nature and Tnlel ► _
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b
<br />WAS CONSENT GRANTED'
<br />1:1 YES I„ 1 NO ❑ UNKNOWN
<br />❑ YES O NO
<br />❑ YES ® N(-
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type a Print)
<br />Sleveei L. N . 21 W o G'ra id rs (a.r,d N E: s? o 3 - --
<br />32a. REGISTRAR
<br />32b DATE FILED BY REGISTRAR /Mo. Day Yr./
<br />If SKI 7 )nnn
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