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202007983 WHEN THIS COPY CARRIES PE RAISED SEAL OF THE NEBRASKA HEALTH AAMAN SERVICES SYSTEM IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE Q JOINAM' O111FJLE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V/TA j STAiI $SE ICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE SEP 27 2002 `-& COOPER ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH Agi M4NI ERV1 SSYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUIONIFAWCESTR4ANNE AND SUPPQRT VITAL STATISTICS 10 2 1 0 9 5 3 CERTIFICATE OF DEATH= 1 DECEDENT - NAME FIRST MIDDLE LAST Mary Esther Lofgreen 2. SEX 13. DATE OF DEATH (Month. Day Yearl Female September 21, 2002 4 CITY AND STATE OF BIRTH Ill not in USA.. name country) Beaver City, Nebraska 5a AGE - Last Birthday (Yrs. l 78 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH Month. Day Year) January 27, 1924 5b. MOS I DAYS 1 5c. HOURS MINS 7 SOCIAL SECURTIY NUMBER p 506-22-8369 8a PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ ER Outpatient ❑ DOA ❑ ❑ Nursing Home Residence Other (SpeUJyr 85. FACILITY - Name dl not institution, give street and number) 2656 O'Flannagan Street 28a. DATE SIGNED (Mo.. Day. Yr) 8c CITY TOWN OR LOCATION OF DEATH Grand Island 8d INSIDE yes CIN LIMITS ri No n 8e COUNTY OF DEATH Halla 9a RESIDENCE - STATE Nebraska 9b COUNTY I Hall 9c CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 19e INSIDE 2656 O'Flannagan St. 68803 1 Yes CITY El LIMITS No ❑ 10 RACE - (e.g., While. Black. Amencan Indian eta, Isoeoifyl White 11. ANCESTRY le.g. Italian. Mexican. German, etc) (Specify)American 12. C MARRIED ❑ WIDOWED ® NEVER ❑ DIVORCED MARRIED 13 NAME OF SPOUSE III wile give maiden name) Reverend Volney D Lofgreen 14a USUAL OCCUPATION !Give kind of work done during most of working Isle. even d retired) Homemaker 145 KIND OF BUSINESS INDUSTRY Domestic 15 EDUCATION (Specify only highest grade cOmpleled/y Elernenlary or Secondary 10.12) Colleg4 )918 0• ' • I `1' 16 FATHER • NAME FIRST MIDDLE LAST Frank VanCleave 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Lora Munger 18 WAS DECEASED (Yesno. or unk.) No EVER IN U.S. ARMED FORCES? 1 (Dyes give war and dates of services) 19a. INFORMANT - NAME I Reverend Volney D Lofgreen 196 INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. ZIP( 2656 O'Flannagan Street, Grand Island, Nebraska 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO. Not Embalmed 22a FUNERAL HOME • NAME All Faiths Funeral Home 21 a METHOD OF DISPOSITION ❑ Burial ❑ Removal OCremation ❑ Donation 216. DATE 21c CEMETERY OR CREMAIOPV NAME September 22, 2002 Westlawn Crematory 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN Grand Island, Nebraska STATE 225 FUNERAL HOME ADDRESS (STREET OR R.F D. NO_ CITU OR TOWN. STATE. ZIP) 2929 S. Locust St. Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 15 Ibl. AND (c)) PART 101 euc.MQ"144V lei 4,t_4fl Inlerval between onset .vnd rleau' DUE TO OR AS A CONSEOUENCE OF 51 Interval between onset and m DUE TO. OR AS A CONSEQUENCE OF Inlerval between onset and dean` OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART II PART III IF FEMALE. WAS THERE A 1 PREGNANCY IN THE PAST 3 MONTHS'' (Ages 10.54) Yes n No n 24 AUTOPSY Yes n No ('Rj 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER, Yes n Nox 26a. . Accident . Undetermined ■ Suicide I. Pending ■ Homicide Investigation 26b DATE OF INJURY (Mo.. Day Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e INJURY AT WORK Yes No ❑ ❑ 261 PLLACE OF INJURY - At home. (arm. street. factory olSce budding. etc /Specify) 26g. LOCATION STREET OR R F.D. NO CITY OR TOWN STATE E N A1-- o P- ,x 27a DATE OF DEATH (Mo. Day. Yr.) September 21, 2002 to be Completed by CORONER S PHYSICIAN o COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day. Yr) 286 TIME OF DEATH M 28c. PRONOUNCED DEAD IMo Day. Yr) 280. PRONOUNCED DEAD tHOurr M 27b. DATE SIGNED /Mo Day Yr) S - .t.3 -rt.. 27c TIME OF DEATH 4:00 P M 28e. On the basis of eeamalion aro investigation, in my opinion death occurred at m 51 the time. dale and place and due to the causels stated. r (Signature and Title)), r 27d. To the best of my knowledgeoccurred a�th�}e time, dpi a]� place and due to the 00. causels) stated. 11 (Signature and Title) II)(/•�'lY/'y A 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ VES Ki NO 30.b WAS CONSENT GRANTED? ❑ YES NO 31. NAME AND ADDRESS 0 CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Pmf) David 'Colan , M.D., 729 North Custer Avenue, Grand Island, Nebraska 68803 32A REGISTRAR Atti5 F'/'/!11 4t4, 32b. DATE FILED BY REGISTRAR (Mo.. Day Yr) AFPa62D02