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20010926'7 Pev 1 U'97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1 O T C 7 O U O d E t0 X 4) I z w w To w 1^ � L LL a O .0 W N Z3 Q Z LL M M t OF(.FDFN7 NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH 14416,914 Der Voted hilt Irma Ella Female Aug ust 10, 2001 4 rR Y AND STATE OF BIRTH lent ln (I.SA name cormeyl 5e AGE - Last BlredaY LINDER 1 YEAR UNDFR -- -- - B DATE OF BIRTH /MMMY. Dar. Yean 5b MOS DAYS 5c HOURS 26d. DESCRIBE HOW INJURY OCCURRED II'rs.I Hall County, Nebraska — 78 1_ 28e INJURY AT WORK January 30, 1923 7 SOCIAL SECURIIY NUMnFn Sa. PLACE OF DEATH 508 -16 -5702 r� HOSPITAL 19 InpnHenl OTHER O Nurs.nq Hpne ❑ ER Ouapabenl ❑ Residence Hb FAC.II.I t Y - Name IA nta mslianMn. prM aeeel and nnnllNll St. Francis Medical Center ❑ DOA ❑ Cathie Sc. CITY TOWNORLOCATIONOFDEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes [� No ❑ Hall 9a RFGIDFNCE STATE COUNTY 9c. CITY, TOWN OR LOCATION 9d STRFETANDNUMPFR IIncIw"IV Codbl _ 9e IN51IK 111, M Nebraska 19b Hall Grand Island 115 W. 23rd St. 68801 Y"K]N- ❑ 10 PACE Ieg.WW, Blaey Amehcenlndian 11. ANCES7 RY le q. Hagan. Mexican. German, etc) 12 W A.RIED a WIDOWED t3 NAME OF SPOUSE (B wb pM maeFn wnN elrllSne�dyl IS11ardy) L NEVER '- DIVORCED White American (�M„�� Forrest J. Pollard I4a UCIIAL OCCU AU()N I(;.ve arrq [M mnrA dn,re tlUrnig =f lii�l -1 15 EDUCAl1pN ISpecIN anN b�QIMM prada cortpMLadl of evi Me. even d ree•ed) 1 ` - -- EMmanlary m Swrordary 10.12) CoMOa It 4 ry •. Owner Food Service 12 18 FATHER NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Friedrich NMN Metterlbrink Magdalene NMN Nuernberger III WAS DECEASED EVER IN US ARMED FOPCES7 198. INFORMANT, NAME (Yet - ("yes I I (H yes give. War and dales M seNiresi No Forrest J. Pollard 1 b _ 1915 INFORMANT MAILING ADDRESS (STREET OR P F D NO. CITY OR TOWN. STATE. ZIPI - 115 W. 23rd St., Grand Island,_ Nebraska 68801 2 EMBALMER. SIGNATURE& LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21J4('(MFtTFfYORC {� E�em�N Park rT0 1 _ 30 h WAS CONSENT GRANTED Not Embalmed ❑Bwlal ❑Removal Aug. 10, 2001 Cremator 31 NAME AND ADD JWL$S (Jf CEPTtFIER IPHYSICIAN. CORONER S P"YRICtAN Otl COUNTY ATTORNFYI (_typoW 5X*. i t- EDAkIV MO 2116 w UT Grand Island, NE 68803 „e FIRORALIMMF -NAME 21d CFMF.TFRYDRCPFMAIDnYt0r.AI10N CITY,- a/AI, Livingston - Sondermann F.H. Grand Island, Nebraska 2215 FUNERAL HOME ADDRESS ISTREF T OR RE O NO CITY On TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE PART dal �L 5", TO. O S A CONSEQUENCE OF IN IFNIF:H ONLY ONE CAUSE PER LINE FOR Ia1. Ibl, AND (c)) I k1NnM bet wa.n daN a-� -v ,•.. I I krMvM baluaerl aril »�.I °a ";• ^. 1 I Wwval h onset arvt —, I ¢I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but nol.eleted PART III IF FEMALE. WAS THERE A I 74 AUTOPSY 25 WAS CASE REFERRED III Ol Da Al PART PREGNANCY IN THE PAST 3040 � %AMINER OR COROFLF R' H (Ages 10 -541 Yes No Yes No Vas No 26a 26b DALE OF INJURY /Mo. Day. Yrl 215c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED 11 A—dent n Undetermined a. M r E] Surcde ❑ Pending 28e INJURY AT WORK 2151 PLACE OF INJURY -lit tto�l�p. Ialm. street. laclory — 26g. LOCATION STREET ORRE.D. NO CITY OR TOWN STATE nHn—ide Invesbgaknn Yas ❑ No ❑ o Ice IMIng, ek:. /SPKay/ 278 DATE OF DEATH (MO. Dar I'll 288. DATE SIGNED (W Day Yr 1 28b TIME OF DEATH - -- - - - -- A-uCt,Sr to AV I a= 1 _ A. M 27b DATE SIGNED /AM. Day Yr) 27c. TIME OF DEATH 2k PRONOUNCED DEAD IAIO. NV Ynl 286, PRONOUNCED iN� fio 200 I IS aM ° ° v 7�Emetbewtofrnyk rgwkdo n. death occurred d HM lime, data and Mace and due to IM -- 280. On HIe basis of examination and or nvesbgaeonl. m my opkabll death oteLanad at .1 Me-1 b ,ts Time. dale end dace and drle to 1M cauaalal s and Tab 1 e and THb 79 DID TOBACCO USE CON 1 RIBUTE TO THE DEATH4 ;Xf a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED _ 30 h WAS CONSENT GRANTED QYES NO � UNKNOWN .� ❑ YES T9 NO ❑ YES NO 31 NAME AND ADD JWL$S (Jf CEPTtFIER IPHYSICIAN. CORONER S P"YRICtAN Otl COUNTY ATTORNFYI (_typoW 5X*. i t- EDAkIV MO 2116 w UT Grand Island, NE 68803 32a REGISTRAR 1311, DATE FILED BY REGISTRAR (ATO. Day, riJ FOR VITAL STATISTICS USE ONLY hereby certify this to be a true and correct copy o; p ori—,:t filed with the State of Nebraska by — — -- Signed in my press sue_ day of Notary ...........E .... ............................Part II .. ............................................ I.................. TMV ......................... .. Census Tract No. .............................. .....1- GENERAL NOTARY -State of Nebraska TERRY L. LOSCHEN My Comm. Exp. - 0