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<br />WHEN TM COPY CARRIES Th E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOI0QHAEE-
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS _0tVM# �S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE LOT 10, VI�DEN SUBDIVISION
<br />TO THE CITY F /��� NLEi* - - - _
<br />AUG 16 1999 0 GRAND s_S= PER.__ =:
<br />HALL COUNT y�� ASSISTAf#4I HATE REQ197FO i -
<br />LINCOLN, NEBRASKA ( , kALTHANDHUMAJtSEffi0WSSY-S.TW •° - ==
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICF,SIIN_ -SORT_
<br />VITAL STATISTICS -�
<br />rrR TTFir A TF nT7 i1R A'Tu
<br />�-rj
<br />to
<br />n
<br />FIRST MIDDLE LAST
<br />2 SEX
<br />Day Y ear/
<br />FUE
<br />Wanda Lea Steckmyer
<br />Female
<br />=17EATH;/�M_onth
<br />, 1999
<br />d. CITY AND STATE OF BIRTH /itch kr U SA.. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year/
<br />X
<br />2>
<br />Lawrenceville, Illinois
<br />Yrs4�o
<br />/ O
<br />January 6, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />Its PLACE OF DEATH
<br />483 -16 -0417
<br />HOSPITAL. ❑ ,patient OTHER ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />8b. FACILITY - Name ///Trot institution. gms sheet and number/
<br />ex St. Francis Medical Center
<br />❑ DOA ❑ Other/Specdv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />fle COUNTY OF DEATH
<br />Grand Island
<br />n
<br />�t
<br />`11)
<br />X
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inc /ud/ng Zip Cone/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2512 W. 4th 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German• etcl
<br />t2. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /k wite. give maiden name/
<br />etc .I lSoeatyl
<br />White
<br />(S
<br />(Specify) American
<br />M
<br />tT
<br />14a. USUAL OCCUPATION��(rr(�Gyive kind of wont done during most
<br />Of ��1� /rmeTllanCr
<br />lab. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed(
<br />Elementary or Secondary 10 -121 College 11 .4 or 5 -I
<br />M
<br />Domestic
<br />27c. TIME OF DEATH
<br />28c. P OUNCED DEAD (Mo.. Day. Ycl
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Elmer C. Simpson
<br />Edna Leach
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />IYesOno. or unk.I
<br />N
<br />(if yes, give war and dates of services(
<br />28e. On ling basis of examination ano,or investigation, in my opinion death occurred at
<br />.1
<br />John Steckmyer
<br />19b. INFORMANT MAILING ADDRESS fSTREET OR R F.D. NO. CITY OR TOWN. STATE. ZIP)
<br />2,512 West 4th Street, Grand Island, Nebraska, 68803
<br />20. ALMER - SIGNATURE 8 LIC E NO.
<br />21. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1236
<br />❑Burial ❑Removal
<br />f
<br />NE C remtic n Servioe
<br />_i M
<br />O
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel - Butler- Geddes
<br />❑X Cremation ❑ Donation
<br />NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type a Print/
<br />Gibbon .Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)I I Interval between onset ano aealn
<br />PART
<br />I
<br />lal I
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<br />WHEN TM COPY CARRIES Th E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOI0QHAEE-
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS _0tVM# �S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE LOT 10, VI�DEN SUBDIVISION
<br />TO THE CITY F /��� NLEi* - - - _
<br />AUG 16 1999 0 GRAND s_S= PER.__ =:
<br />HALL COUNT y�� ASSISTAf#4I HATE REQ197FO i -
<br />LINCOLN, NEBRASKA ( , kALTHANDHUMAJtSEffi0WSSY-S.TW •° - ==
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICF,SIIN_ -SORT_
<br />VITAL STATISTICS -�
<br />rrR TTFir A TF nT7 i1R A'Tu
<br />�-rj
<br />to
<br />n
<br />FIRST MIDDLE LAST
<br />2 SEX
<br />Day Y ear/
<br />FUE
<br />Wanda Lea Steckmyer
<br />Female
<br />=17EATH;/�M_onth
<br />, 1999
<br />d. CITY AND STATE OF BIRTH /itch kr U SA.. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year/
<br />Sb MOS DAYS
<br />Sc HOURS MI_
<br />Lawrenceville, Illinois
<br />Yrs4�o
<br />/ O
<br />January 6, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />Its PLACE OF DEATH
<br />483 -16 -0417
<br />HOSPITAL. ❑ ,patient OTHER ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />8b. FACILITY - Name ///Trot institution. gms sheet and number/
<br />ex St. Francis Medical Center
<br />❑ DOA ❑ Other/Specdv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />fle COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑ No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inc /ud/ng Zip Cone/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2512 W. 4th 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German• etcl
<br />t2. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /k wite. give maiden name/
<br />etc .I lSoeatyl
<br />White
<br />(S
<br />(Specify) American
<br />NEVER DIVORCED
<br />John Steckmyer
<br />14a. USUAL OCCUPATION��(rr(�Gyive kind of wont done during most
<br />Of ��1� /rmeTllanCr
<br />lab. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed(
<br />Elementary or Secondary 10 -121 College 11 .4 or 5 -I
<br />M
<br />Domestic
<br />27c. TIME OF DEATH
<br />28c. P OUNCED DEAD (Mo.. Day. Ycl
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Elmer C. Simpson
<br />Edna Leach
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />IYesOno. or unk.I
<br />N
<br />(if yes, give war and dates of services(
<br />28e. On ling basis of examination ano,or investigation, in my opinion death occurred at
<br />.1
<br />John Steckmyer
<br />19b. INFORMANT MAILING ADDRESS fSTREET OR R F.D. NO. CITY OR TOWN. STATE. ZIP)
<br />2,512 West 4th Street, Grand Island, Nebraska, 68803
<br />20. ALMER - SIGNATURE 8 LIC E NO.
<br />21. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1236
<br />❑Burial ❑Removal
<br />Jul 30 , 1999 C&Itral
<br />NE C remtic n Servioe
<br />22a. FUNERAL HOME - NA
<br />❑ YES ® NO
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel - Butler- Geddes
<br />❑X Cremation ❑ Donation
<br />NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type a Print/
<br />Gibbon .Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)I I Interval between onset ano aealn
<br />PART
<br />I
<br />lal I
<br />I
<br />rmervai cetween onset ana seam
<br />Q
<br />r�
<br />DUE TO. OR AS A CONSEOUIENCE OF:
<br />1 interval between ancet anti ^Pam
<br />Icl
<br />!
<br />OTHER SIGNIFICANT CONDITIONS - Conditions Contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />2d AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />If
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />(Ages 10 -Sa! Yes No r7ii
<br />yes No
<br />Vey No
<br />26a
<br />26b. DATE OF INJURY /Mo.. Day. VcJ
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident 1-1 Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJURY - At ho . term. street. factory
<br />ce bmkkng, etc / Specifry/
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN - STATE
<br />Homicide Investigation
<br />E❑
<br />yes No ❑
<br />27a. DATE OF DEATH /MO.. Day Yr/
<br />28a. DATE SIGNED (Mo.. Day YrI
<br />28b TIME OF DEATH
<br />a27b
<br />�UQ
<br />Q
<br />M
<br />DATE SIGNED /MO.. Day. rrl
<br />27c. TIME OF DEATH
<br />28c. P OUNCED DEAD (Mo.. Day. Ycl
<br />28d. PRONOUNCED DEAD /HOU
<br />g�
<br />M
<br />J
<br />g=�°
<br />Jul 26, 1999
<br />M
<br />°
<br />27d. To the best W my knowledge. death occurred at the lime, data and dace and due to Me
<br />28e. On ling basis of examination ano,or investigation, in my opinion death occurred at
<br />.1
<br />causels) stated.
<br />° a
<br />the time. date and piece a ca e(sl slateq.
<br />(Si nature and Title
<br />Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />.b WAS SENT GRANTED?
<br />❑ YES ❑ NO � UNKNOWN
<br />❑ YES ® NO
<br />❑ YES ®
<br />NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type a Print/
<br />32a REGISTRAR
<br />32t( DATE FILED BY REGISTRAR /MO.. Da .
<br />AUG 13 W9
<br />u
<br />1
<br />
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