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y 2 SEX 3. DATE OF DEATH MOnvf Dar Yea,) n� �_ Male + October 28, 2000 4 CITY AND STATE OF BIRTH 111 not in US. A. name countryl 5a. AGE - Last Birthday UNDER 1 YEAR o �z n N gypp` m s-. �. (Y's 1 89 June 19, 1911 7. SOCIAL SECURTIV NUMBER _ Be . PLACE OF DEATH -� n HOSPITAL FL1 Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence O St. Francis Medical Center ❑ DOA ❑ other Bc CITY TOWN OR LOCATION OF DEATH Btl INSIDE CITY LIMITS v m ri r u Yes ® N° ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY �J 9d STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS Nebraska Da 1 1023 W. 9th 68801 Yes © No ❑ 10. RACE - leg.. White, Black. American Indian. 11. ANCESTRY le q Italian. Mexican. German. etc( CAD CO Q etc.)(Spectbl White (Specify) German NEVER DIVORCED MARRIED_ Leona H. Fletcher 14a. USUAL OCCUPATION /Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working life, even if renredl Assistant Postmaster United States Post Office Elementary or S rclary 10.12) C Ilege 11 -4 of i- 1 16. FATHER -NAME FIRST MIDDLE LAST 1 MOTHER FIRST MIDDLE MAIDEN SURNAME William Poppe �N ti e� 1 V r WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA4 RVICES SYSTEM, IT CERTFF/ES THE BELOW TO BE A TRUE COPY OF THE O _ � E,W/TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V►TA llilGFl IS THE LEGAL DEPOSITORY FOR VITAL RECORDS T DATE OF ISSUANCE Nov 7 2000 2000101-21 a FOR 5SI41STA91t1^ d�TRAR LINCOLN, NEBRASKA HEALTH*0 VOYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND 6_ �rIC_ES FW E AND SUPPORT VITAL STATISTICS H E -' CERTIFICATE OF DEATHS nN C D z --a --1 M -< o C) -n m z ZZ rT1 D co r" �7 r D D co N 91 O CD O O. O N N F-, CD t—+ N co O I DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH MOnvf Dar Yea,) Odin William Poppe Male + October 28, 2000 4 CITY AND STATE OF BIRTH 111 not in US. A. name countryl 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH iMon#7 Dav Year) 5b MOS DAYS 5c HOURS MINT Yankton, South Dakota (Y's 1 89 June 19, 1911 7. SOCIAL SECURTIV NUMBER _ Be . PLACE OF DEATH 506 -09 -6642 n HOSPITAL FL1 Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b FACILITY - Name (If not mstitubon, give street and number) St. Francis Medical Center ❑ DOA ❑ other Bc CITY TOWN OR LOCATION OF DEATH Btl INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand Island Yes ® N° ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1023 W. 9th 68801 Yes © No ❑ 10. RACE - leg.. White, Black. American Indian. 11. ANCESTRY le q Italian. Mexican. German. etc( 12 ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE !If wde gve maiden name) etc.)(Spectbl White (Specify) German NEVER DIVORCED MARRIED_ Leona H. Fletcher 14a. USUAL OCCUPATION /Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working life, even if renredl Assistant Postmaster United States Post Office Elementary or S rclary 10.12) C Ilege 11 -4 of i- 1 16. FATHER -NAME FIRST MIDDLE LAST 1 MOTHER FIRST MIDDLE MAIDEN SURNAME William Poppe Caroline Berreth 18 WAS DECEASED EVER IN U.S. ARMED FORCES? _ 19a INFORMANT NAME (Yes no or unk.) III yes. give war and dates of services) M Yes: VM II 5/21/1943 12/6/1945 Leona H. Poppe 191b, INFORMANT MAILING ADDRESS (STREET OR RP D NO_ CITY OR TOWN. STATE. ZIPI 1023 West 9th, Grand Island, NE. 68801 EMB LINER_/ I NATURE8L1 N N O v v Sit 27 a. METHOD OF DISPOSl7!ON 276. DATE 2tc CEMETERY OR CREMAT CRY NAME / 7 jam; Burial ❑ rn Re°�al !IQCt. 31, 2000 Grand Island Cemetery_._ u 121n CEMETERY OR CREMATORY LOCATION CITY 'DP TOWN STATE 22a FUNERAL ROME - NAME A fel- Butler - Geddes ❑ Crema "pn El D °,a "° Grand Island NE. _ 22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, Nebraska 68801 I I ) LJ IMMtUTA I t 1-i PART Ial DUE TO, OR AS AC Ibl DUE TO OR AS A C It) 'tN I tH ONLY UNt U-11 ✓t' Lhvt rUH =dl Iol. ANIJ cll imer1a1 oerween onser ann near 1 Interval between onse and near, Interval between onset ann dean OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related I PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART 11 PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER' IAgeS !0 -SA) Yes ❑ No ❑ Yes ❑ No Yes ❑ No 26a 26b. DATE OF INJURY fMo. Day. Yc) 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED Accident Undetermined I' M Suicide F] Pending 26e. INJURY AT WORK 261 PLLACE OF INJURY - At home farm sleet factory 26q LOCATION STREET OR R 0. NO - TY OR TOWN STAT ❑Homicide Investigation yes ❑ ❑ ollice building. etc /Investigation No 27a. DATE OF DEATH IMO.. Day Yr) 28a DATE SIGNED IMO_ Day YU 281b TIME OF DEATH - M �A $ >' ° 27b DATE SIGNED / o.. Day. yd 27c TIME OF DEATH 28C PRONOUNCED DEAD rMo. Day. Y0 280. PRONOUNCED DEAD IHOUrI J V J t7 / 3 c, M w z m M 27d. To the best of knowledge death occurred at ti e. date and place and due to the 28e On the basis of examination and or iovesbgaeon, in my opinon death occurred at ' i cause(sl statetl. ° the time. date and place and due to the cause(sl stated. _, 7l (Sf nature and Tillel 0, ITr nature and Titlel ► 29 DID TOBACCO USE CONTRIBUT O THE DEATHS ♦/ 3Qa. AS ORGAN OR TISSUE DONATION BEEN C SIDERED� 30.b WAS CONSENT GRANTEO> ❑ YES NO ❑ UNKNOWN ❑ YES NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY I Type or Pnni/ Gordon J. Hrni ek M.D 29 N. Custer, Grand Island, NE. 68803 32a. REGISTRAR 32b DATE FILED BY REGISTRAR /MO. Day Yr) I. hinv a )nnn SO