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�oe�o�aoo - WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA_Lf -hVMAN S CES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE 02- MAL�i9EC61�ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA01(**$T &M M, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. Fes= #A" DATE OF ISSUANCE JUL /r $ 2000 IIjSS/3�ANT 5MADII OISTRAR LINCOLN, NEBRASKA HEALII�LANDi r' SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND jj.MAM tq E AND SUPPORT VITAL STATISTICSi° ' — CERTIFICATE OF DEAD- .— �1 DECEDENT - NAME FIRS' - - - -- MIDDLE -- LAST 2 SEX 7 3 Da7F OF DEATH Miv,rr• 11a i Pearl-- - -_ - -- - - Ruth L• Hetrick Female July 21, 2000 a CITY AND STATE OF BIRTH Nf notin U S A.. name couatryl 5a AGE - Last Biehday UNDER T YEAR UNDER 1 DAY 6 DATE OF BIRTH !Month. Dal, Yedrl Lake Manama, Iowa Y's, 77 Sb MOS i DAYS 5c HOURS MINS October 30, 1922 7 SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH - —" 507- 16 -8182 x HOSPITAL Inpatient OTHER ❑ Nursing Holne ❑ ER Outpatient El Residence Bb. FACILITY Name (If not mshtution, give street and number! St. Francis Medical Center ❑ DOA ❑ Other ;Spec#, Be CITY TOWN OR LOCATION OF DEATH Btl INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand Island Yes X❑ No ❑ Hall - 9a. P.ES:DESIC_ -STATE 97-G6t1M'1'7 - 9[ CITY. TOWN OR LOCATION 9d. STREET AND NUMBER :Inc)uding Zip Cadet 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 232 N.Ruby 68803 Yes ® No ❑ 10 RACE (e.g.. Whde. Black. American Indian t t. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE tit wife give maiden name) etc.) (SOeci (Specify) YVh l.te American NEVER DIVORCED ❑ MARRI Merwin Hetrick 1 14a USUAL OCCUPATION /Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION Speofy only highest grade completed) of working life. even d retired) Housewife Domestic Elementary or Secondary 10 12) College 11 16 FATHER - NAME FIRST MIDDLE LAST n MOTHER FIRST MIDDLE MAIDEN SURNAME Earnest Kiesel Stella Steuben 18. WAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT NAME _ o unk l If yes give war and dales of services) j NeSOnp Merwin Hetrick 19b INFORMANT MAILING ADDRESS (STREET OR R F D NO CITY OR TOWN. STATE. ZIP( -- - -- 232 N. Ruby, Grand Island, NE. 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO 21a. METHOD OF DISPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME Not Embalmed El Bunal F] Removal July 22, 2000 ICentral Nebraska Cremation_ 22a FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes a Cremation p Dorr Gibbon, Nebraska _ 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, NE. 68801 23. IMMEDI TIE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND loll Interval between onset and seam PART I (a) M C e A f�x.�-e DUE TO. OR AS A CON EO ENCE OF Interval between onset and ream DUE TO OR AS CONSEOUE _ Interval between onset and Beau (c) I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 2a 4UTOPSv 25. WAS CASE REFERRED 70 MEDICAL II PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER' (Ages 10 -561 Yes No Vas No _ Yes ❑_ No� 26a 261 DATE OF INJURY (MO.. Day. Yr.; 26C HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED F] Accident F] Undetermined M Suicide F] Pending 26e INJURY AT WORK 261 PLACE OF INJURY - At home. (arm street factory 26g LOCATION STREET OR R.F D NO. CITY OR TOWN STATE otiice building. etc 'Specify) Homicide Investigation Yes No ❑ 27a DATE OF DEATH rMO. Day ✓rl 28a DATE SIGNED /MO. Day yr; 28b TIME OF DEATH July 21,2000 ' a w M ga i 27b. DATE SIGNED (Me Day yo 27c. TIME OF DEATH 28c PRONOUNCED DEAD IMO Day. Yr 1. _ 28d. PRONOUNCED DEAD Moue ggo July 21,2000 20pm) M °aJ w o M g z 27d. To the best d my k th occurred the me, d to and place and tlue w the 28e. On the basis of examination and or ,evesugatlon, In my opinion death occurred at a ° ° ° cause(sl star the vne, date and place and due to the causelsl stated (Signature and Tdle ► (Signature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TO TI-If EATH? 30.a AS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' ❑ YES FT NO UNKNOWN ❑ YES- ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) 809 N,, Alpha Ave., Grand Island, NE. 68803 32a REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.( AA Id` tits JUL 2 7 2000 [►