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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, -WHICH IS <br />THE LEGAL DEPOSITORY FOit6T�LiBVCO�t2.2 3 <br />DATE OF ISSUANCE ff 1 a� <br />JAN 2 6 2001 <br />LINCOLN, NEBRASKA <br />�/���j <br />� BiANLE <br />200100993 YS. COOPER <br />ASSISTANT STATE REGISTRAR <br />HEALTH A?D HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS ' <br />CERTIFICATE OF DEATH; <br />1 DECEDENT - NAME <br />FIRST MIDDLE LAST <br />Donald Arthur Rice <br />2 SEX <br />Male <br />3. DATE OF DEATH ,Monrn Day Year) <br />December 22, 2000 <br />4 CITY AND STATE OF BIRTH Al not in US. A.. name country) <br />Dunning, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs , 73 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />5b MOS I DAYS <br />Sc. HOURS MINS. <br />6. DATE OF BIRTH (Mont. Day Year) <br />April 27, 1927 <br />7 SOCIAL SECURTIY NUMBER <br />520-28-6383 <br />8b. FACILITY - Name (If not rnsetueon, give street and number) <br />Univeristy of Nebraska Medical Center <br />Ba PLACE OF DEATH <br />HOSPITAL. ® Inpatient OTHER. El Nursing Home <br />ER Outpatient EI Residence <br />LDOA <br />❑ Other (Spect/vr <br />8c CITY. TOWN OR LOCATION OF DEATH <br />Omaha <br />1 8d NSIDE CITY LIMITS I Be. COUNTY OF DEATH <br />r <br />I Yes E No L] � Douglas <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />9c CITY TOWN OR LOCATION <br />Alda <br />9d. STREET AND NUMBER /Including Zp Code) <br />305 W. 3rd <br />9e INSIDE <br />Yes <br />CITY <br />X <br />LIMITS <br />No ❑ <br />10 RACE - le g., White. Black American Indian. <br />etc./ ISoeclfy <br />White <br />11. ANCESTRY le.g.. Italian. Mexican. German. etcl <br />ISWctfS <br />American <br />12 <br />ri <br />❑NEVER <br />MARRIED ❑ WIDOWED <br />❑DIVORCED <br />MARRIED <br />13 NAME OF SPOUSE (It why gree maiden name) <br />Lauretta Barnes <br />tda. USUAL OCCUPATION (Give kind of work done during most <br />of working He, even n retired) - <br />-Laborer <br />146 KIND OF BUSINESS INDUSTRY <br />Construction Company <br />15 EDUCATION (Speciy only hgnest grade completed) <br />Elementary or Sec ry 10.121 College n-4 or ,-i <br />�°� <br />16. FATHER - NAME FIRST MIDDLE LAST <br />Delbert Rice <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Willa Mildred Warren <br />18 WAS DECEASED EVER IN OS ARMED FORCES? +9n INFORMANT - NAME <br />(Ys. nn.: unKoreang�Ve w2 and dates <br />a 19s52esl 1-21-1954 1 <br />Yes: � <br />Lauretta Rice <br />I 9b INFORMANT MAILING ADDRESS <br />(STREET OR R D NO. CITY OR TOWN STATE. ZIP) <br />305' West 3rd, Alda, NE. 68810 <br />20 EMBALMER - SIGNATURE 8 LICENSE NO. <br />a FUNERAL HOME - NAME <br />Apfel-Butler-Geddes <br />21a METHOD OF DISPOSITION 21b. DATE <br />® Bur -al ❑ Removal <br />Cremabor Dona/or <br />21c. CEMETERY OR CREMATORY NAME <br />Dec. 27,2000 Westlawn Memorial Park <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, NE. <br />22b FUNERAL HOME ADDRESS (STREET OR RF NO CITY OR TOWN. STATE. ZIP( <br />1123 West Second, Grand Island, NE. 68801 <br />23 IMMEDIATE CAUSE <br />PART <br />//J 4 /y <br />,4 ! - r�,r�% <br />Ia1 y <br />DUE 0. OR A6 A CONSEOUENCE OF <br />r <br />(ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (cl) <br />Interval between onset ann (teal <br />rot c ' / /Yr-1J-rr /On ,c/ fye.o, a,✓1�4 <br />DUE TO. OR AS A. CONSEQUENCE OF <br />tot <br />Interval between onset and neat, <br />Interval between Yr4PI a^^'•?.f <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />II <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages t0 -Sal Yes I n 1 NoYes1Sr <br />24 AUTOPSY <br />No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Li No n <br />26a <br />. Accident . Undetermined <br />II Smctde II Pending <br />. Homicide Investrgatlon <br />26b. DATE OF INJURY (Mo.. Day. Yr/ <br />26c HOUR OF INJURY <br />M <br />..Yes <br />26d. DESCRIBE HOW INJURY OC URRED <br />26e. INJURY AT WORK <br />Yes No <br />❑ ❑ <br />261 PLACE OF INJURY - At home. farm. street. factory <br />office budding. etc lSpeciyl <br />26g. LOCATION STREET OR R D. NO CITY OR TOWN STATE <br />E <br />14 <br />p <br />27a. DATE OF DEATH (Mo. Day Ye) <br />12/22/2000 <br />10 be Canpeied by <br />CORONER'S PHYSICIAN <br />a COUNTY ATTORNEY <br />ONLY <br />28a DATE SIGNED (Mo. Day Yr I <br />28b TIME OF DEATH <br />M <br />28c PRONOUNCED DEAD (Mo.. Day. Yc) <br />280. PRONOUNCED DEAD /Noun <br />M <br />27b. DATE SIGNED (Mo Day Yr/ <br />I 1c ? 12<w r <br />27c TIME OF DEATH <br />0315AM M <br />28e On the basis of examination and or investrgation. in my opinion death occurred at <br />time, date and place and due to the causels) stated. <br />op. (Signature and Title) <br />27d To the best of m no ledge • <br />' causels) stated.the <br />(Signature and Title) -..- <br />_ • cuffed at time. date and place and due to the <br />29 DID TOBACCO USE CONT- :UTE To A- DEATH? <br />YES a .NO.. Li UNKNOWN <br />30.a HAS ORGAN OR TISSUE DONATION <br />Li YES <br />BEEN <br />?C <br />CONSIDERED? <br />NO <br />30.b WAS CONSENT GRANTED? <br />Li YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type Or Pnntl <br />J f ec7--r- MCA,. .'s'I1 i .� r/ttlk, ,a1.fa/�( Cr,�, ,- vhv,,,ra �c R15'S --�f� 1 <br />32a. REGISTRAR � �V � <br />' <br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) <br />JAN 1 0 2001 <br />