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WI:EN THOS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SYSTEM IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 902004542 ASS T, �T ' -' • -• HEALTH AND Fes x S!5 hep S S1 STEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SOtV(S F, NDSHPPORT ; .. VITAL STATISTICS -_ 02 0396 CERTIFICATE OF DEATH - __ DATE OF ISSUANCE APR 1 0 2002 LINCOLN, NEBRASKA I. DECEDENT - NAME FIRST MIDDLE LAST Cecelia Burns Wagoner 2. SEX Female UNDER 1 DAY 3. DATE OF DEATH (Month. Day. Year) March 22, 2002 6. DATE OF BIRTH (Month. Day. Year) 4. CITY AND STATE OF BIRTH ill not,, USA.. name country) 5a. AGE - Last Birthday UNDER 1 YEAR Yuma County, Colorado (Yrs) 89 SD MOS I DAYSS Sc. HOURS i MINS March 10, 1913 l�iCil 7 SOCIAL SECURTIY NUMBER 506-20-2582 Ba. PLACE OF DEATH HOSPITAL K Inpatient OTHER. ❑ Nursing Home - ❑ ER Outpatient ❑ Residence ❑ DOA Other (Specify) • Bb. FACILITY - Name (If not give street and number) St. Francis Medical Center 28a DATE SIGNED (Mo.. Day. Yr 1 Bc. CITY. TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS Yes [ cJ No ❑ 8e COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Wood River 9d. STREET AND NUMBER (Including Zip Code) 1411 Walnut 68883 9e. INSIDE Yes CITY P.7 LIMITS No ❑ 10. RACE - (e g., White. Black. American Indian. etc.) ISoele 1 Wi�te 11. ANCESTRY (e.g.. Italian. Mexican, German. etc) (Speedy) Irish 12. ❑ MARRIED NEVER . MARRI x ❑ WIDOWED DIVORCED 13 NAME OF SPOUSE (If wile. give maiden name) X77 lhol��as J. Wagoner (dec) 14a. USUAL OCCUPATION (Give kind of work done during most of working life, even if retired) Bookkeeper 14b. KIND OF BUSINESS INDUSTRY Ordinance Plant 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10-12) : College (1-4 or 5•) 4 16. FATHER - NAME FIRST MIDDLE John C. LAST Burns 17 MOTHER FIRST Lena MIDDLE MAIDEN SURNAME Moffitt 18. WAS DECEASED EVER IN U.S. ARMED FORCES? (Yes. noor unt) ID yes. give war and dates of services) No 19a. INFORMANT - NAME Judy Wagoner 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1716 S. Curtis Street Grand Island, NE 68803 20. EM ER - SIGN[1TURE 8 LICENS NO /2 V0 22a FUNERAL HOME - A E Apfel Funeral Home 21 a. METHOD OF DISPOSITION ® Burial ❑ Removal ElCremation El Donation 21b. DATE 21c. CEMETERY OR CREMATORY . NAME 3/25/02 St. Mary's Cemetery 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Wood River, NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 411 West 11th St. P.O. Box 126 Wood River, NE 68883 23. IMMEDIATE CAUSE PART n lal Li O L. O L i DUE%'I�Oj RASA ON,SEO/UENCE�/OP (b)�/ Y� lt ,C/ 66' / , 7��'i.x.tia DUE TO. OR AS A CONSEOUENCE OF- r (c) s -b(1 �G1,-l� - ) (ENTER ONLY ONE CAUSE PER LINE FOR la). Si). AND (c)l Interval between onset and death Interval between onset and death Interval between onset and deatn OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART II PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS' (Ages 10-54) Yes n No 24 AUTOPSY Yes n No - 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONFji'I lly�l Yes ❑ No 26a Accident II Undetermined II Suicide IN Pending . Homicide Investigation 26b. DATE OF INJURY (Mo., Day. Yr) 26c. HOUR OF INJURY M 264. DESCRIBE HOW INJURY OCCURRED ( 26e. INJURY AT WORK yes No ❑ ❑ 261 PLACE OF. INJURY - ppt home, farm. street factory office building, etc. l$pecii ) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE To oe Compelee 0y Aeenorng PHYSICIAN ONLY 27a. DATE OF DEATH (Mo.. Day. Yr.) March 22, 2002 To be Completed by CORONERS PHYSICIAN L or COUNTY ATTORNEY ONLY 28a DATE SIGNED (Mo.. Day. Yr 1 28b. TIME OF DEATH M 27b. DATE SIGNED (Mo.. Day Yr.) March 2 ',-2002 27c. TIME OF DEATH 5:45 A M 28c PRONOUNCED DEAD (Mo.. Day. Yr.) 28d. PRONOUNCED DEAD (Hour) M 274. To the best of my k owledgyeath occurred at the b . date and place and due to the 110. 2 causelsl stated. '-- (Signature and Title) b 28e. On the basis of examination and or investigation, in my opinion death occurred at ' the time, date and place and due to the cause(s) slated. (Signature and Title) ► 29. DID TOBACCO USE CONT • :UTE,TO THE DEATH? ❑ YES lig, 0 ❑ UNKNOWN t , 30.a HAS ORGAN OR TISSUE DONATION EN CONSIDERED? ❑ YES NO 30.b WAS CONSENT GRANTED? �,(f ❑ YES ' NO 31. NAME AND ADDRESS OF RTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or P I) John Wagoner M.D. 800 Alpha T ,rand 'Wand tte 6RR43 32a. REGISTRAR • elI 32E4 DATE FILED BY REGISTRAR (Mo.. Day. Yr.) APR 8 2002