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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM,ITCERTIFIESTHEBELOWTOBEATRUECOPYOFTHEORIGINALRECORDONFILEWITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />JAN 2 8 2002 <br />LINCOLN, NEBRASKA <br />201903860 <br />ANDY S COOPER <br />ASSISTANT STATE REGIST1AR <br />HEALTH AiV HUMAN SERVICES SY$`EM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SIERVICESEINANCiANDIUTIPORT <br />CERTI VITCATE o DEAD 02 00559 <br />I I. DECEDENT • NAME FIRST MIDDLE LAST <br />Beverly Jane Gronewold <br />2. SEX. a <br />Female <br />1 DATE OF DEATH (Monte Day. Year) <br />Jan 23 2002 <br />4. CITY AND STATE OF BIRTH if not ei USA. name country) <br />Osmond, Nebraska <br />5a. AGE -.Last Birthday <br />(Yrs-) <br />52 <br />UNDER 1 YEAR <br />UNDER I DAY <br />6. DATE OF BIRTH (Mo10h. Day. Year) <br />Jun 6 1949 <br />51). MOS. I DAYS <br />5c. HOURS I MINS <br />7. SOCIAL SECURTIY NUMBER <br />507-68-4226 <br />Ba PLACE OF DEATH <br />HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Home <br />❑ ER OLVaOera <br />❑ DOA <br />X <br />❑ <br />Residence <br />Ober (Specrryl <br />6b. FACILITY - Name (tent ulsteueon, give steel and mambo) <br />3104 Midway Rd. <br />27a. DATE OF DEATH (Mo.. Day. `Yr.r.) <br />a <br />Clic. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island <br />6d. INSIDE <br />Yes <br />CITY UNITS <br />X No ❑ <br />8e. COUNTY OF DEATH , <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d STREET AND NUMBER (Including Zip Code) <br />3104 Midway Rd. 68803 <br />9e INSIDE <br />Yea <br />CITY <br />X <br />LIMITS <br />No ❑ <br />10 RACE - (e -g., White. Black. American Indian. <br />etc.) ISpemly) <br />White <br />11. ANCESTRY le.g.. Italian. Mexican, German. etc) <br />ISpedfy) <br />German/Swedish <br />12. [L �r <br />MARRIED ❑ WIDOWED <br />MEARRIED VER ❑ DIVORCED <br />13. NAME OF SPOUSE (e wee. give maiden name) <br />Donald Gronewold <br />14a USUAL OCCUPATION /Give kindotwwk done doxp moat <br />o/ waking ale, even d renredl 1.11 <br />Licensed Practical Nurse <br />1415. KIND OF BUSINESS INDUSTRY <br />Health Car <br />.0 W 6" <br />o a <br />t5. EDUCATION (Specify only highest grade compleled) <br />Elementary 2 Secondary 10-12) College II 4 or 5-i <br />1 <br />t6. FATHER - NAME FIRST MIDDLE LAST <br />Allen Johnson <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Elva Mae Jensen <br />WAS DECEASED <br />(Yes. no. or unk.) <br />No <br />EVER IN U.S. ARMED FORCES? <br />I I6 yes. give war and dates of services) <br />/ / / / <br />19a. INFORMANT - NAME <br />Donald Ray Gronewold <br />190. INFORMANT MAILING ADDRESS (STREET OR RFD. NO.. CITY OR TOWN. STATE. ZIP) <br />3104 Midway Rd. Grand Island, NE 68803 <br />20. EMBALMER- SIGNATURE a LICENSE NO. <br />Not Embalmed <br />21a METHOD OF DISPOSITION <br />❑Burial ❑Renoval <br />X Cremation ❑ Donator, <br />210. DATE <br />Jan 23, 2002 <br />21c. CEMETERY OR CREMATORY - NAME <br />Central Nebr. Cremation <br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />719 Front St. Gibbon NE <br />220. FUNERAL HOME - NAME <br />Curran Funeral Chapel <br />2215. FUNERAL HOME ADDRESS (STREET OFt R.F.D. NO.. CRY OR TOWN. STATE. ZIP) <br />3005 South Locust Street, Grand Island, NE 68801 <br />23. IMMEDIATE CAU <br />PART <br />fa) Me q L C�i <br />DUE TO. OR AS A CONS OF: <br />1b) <br />DUE TO. OR AS A CONSEOUENCE OF. <br />(ENTER ONLY ONE CAUSE PER LINE FOR lel. Ib). AND (c))) ,1 • [� (/a' Interval between onset and <br />death <br />rit e+o oC. ,will, (1211 n// Lc.f%j �^t� Interval ousel and death os <br />✓ Interval between oresi:l and deals <br />ICI <br />�OTHER SIGMFICANT CONDITIONS - Conditions odltibetp b the death but not related <br />PART <br />It <br />H <br />PAIF FEMALE. WAS THERE A <br />IN T <br />(Ages 1 -54) THE Li No <br />A1. AUTOPSY . <br />Yes ❑ No X <br />!MAMAS CASE REFERRED TO <br />OR CORONER, <br />EXAMINER <br />Yesn No <br />MEDICAL <br />E <br />26a. <br />• Accident • Undetermined <br />• Suicide U Pending <br />• Homicide Investigation <br />2615. DATE OF INJURY (Md_ Day Yr,) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yea ❑ No ❑ <br />261. PLACEOF Kir �Al tx>Rn9, farm. street factory <br />office Dutdl SPecay) <br />26E LOCATION STREET OR RF.D. NO. CITY OR TOWN STATE <br />e <br />27a. DATE OF DEATH (Mo.. Day. `Yr.r.) <br />a <br />26a. DATE SIGNED (Mo.. Day. Yr.) <br />260. TIME OF DEATH <br />1g <br />.2fiDATE SIGNED (Ma. Day. Yr.) ,; <br />I / 3/0� <br />Z Ba TIME OF DEATH _ <br />Z ., ,_ <br />28c. PRONOUNCED DEAD (Ab.. Day, Ye) <br />28d. PRONOUNCED DEAD /Hour) <br />B§ <br />Ia: 3,l a., <br />8Eig <br />N <br />27d. To the best of my knowledge. death <br />,d. <br />0cause(sl stale <br />(Signature and e) IP <br />occurred at the lime, to and place anddue to the <br />( <br />1'(SignatureTitl <br />.0 W 6" <br />o a <br />28e. On the basis of esammatron anise investigation, It my opinion death occurred at <br />the time, date and place and due to the camels slated. <br />Pr' ' (Signature and TISe) ► <br />I TOBACCO USE CONTRIBUTE TOTI <br />ErYES ❑ NO <br />T 7 <br />❑ UNKNOWN <br />Spa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />YES 1140❑ <br />3815 WAS CONSENT GRANTED? <br />VES <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) <br />Sitki Copur 2116 W. Faidley Ave., Grand Island, NE 68803 <br />32a. REGISTRAR <br />A A <br />320. DATE FILED BY REGISTRAR (Ma, Day. 'Yr) <br />JAN 2 5 2002 <br />4 <br />