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WHEN -,HIS COPY CARRLES THE RAISED SEAL OF THE NEBRASKA HEALFH�WAN SERVICES SYSTEM, R CER77FES THE BELOW TO BE A TRUE COPY OF THE ORiMULAECO .ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VIT/ 1pW87 891P7 !I, WHICH 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUL 2 8 2000 200010159 Aasisuwsr ISTRAR LINCOLN, NEBRASKA HEALIW AND AUNANAERVICIS SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND NM SER1NgpjE AND SUPPORT VITAL STATISTICS: - - CERTIFICATE OF DEA14+:i '` I DECEDENT NAME FIRS' MIDDLE LASI 22 SEX 1 MM Ruth L. Hetrick O --j O in C D ;r n D Z C! Lake Manawa, Iowa IY,I 77 rn N 171,11 o o N HOSPITAL lnpatlent OTHER ❑ Nur, Hoene VI j- ► Q T Q.I. CA ❑ DOA ❑ Other r$pecd, 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 9e COUNTY OF DEATH _ a Z �Ti C:) 9c CITY. TOWN OR LOCATION ni Nebraska Hall 6 232 N.Ruby 68803 Yes No ❑ � �p 13 NAME OF SPOUSE fit wto give maiden name) O -r WHEN -,HIS COPY CARRLES THE RAISED SEAL OF THE NEBRASKA HEALFH�WAN SERVICES SYSTEM, R CER77FES THE BELOW TO BE A TRUE COPY OF THE ORiMULAECO .ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VIT/ 1pW87 891P7 !I, WHICH 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUL 2 8 2000 200010159 Aasisuwsr ISTRAR LINCOLN, NEBRASKA HEALIW AND AUNANAERVICIS SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND NM SER1NgpjE AND SUPPORT VITAL STATISTICS: - - CERTIFICATE OF DEA14+:i '` I DECEDENT NAME FIRS' MIDDLE LASI 22 SEX 1 D ,'�tF �F DFA - - - fH Af n (tat. lea; Ruth L. Hetrick O --j O 4. CITY AND STATE OF BIRTH Ift nol in USA.. name counlryl C D UNDER I YEAR UNDER t DAY 6 DATE OF BIRTH /Month. Dar Year) Lake Manawa, Iowa IY,I 77 rn 5c HOURS MINIS o o N HOSPITAL lnpatlent OTHER ❑ Nur, Hoene _______ —___. _... 27a DATE OF DEATH /MO Day YrI �28a DATE SIGNED /MO. Day Yr; 28o TIME OF DEATH j- ► Q T O ❑ DOA ❑ Other r$pecd, 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 9e COUNTY OF DEATH _ Grand Island Z �Ti C:) 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER acluding Ztp Codel 9e MSIDE CITY LIMITS Nebraska Hall Grand Island 232 N.Ruby 68803 Yes No ❑ 10. RACE - le.g.. White. Black. American Indian 11. ANCESTRY le.g.. Italian. Mexican. German, etc) 12. K] MARRIED ❑WIDOWED 13 NAME OF SPOUSE fit wto give maiden name) O -r En 14a USUAL OCCUPATION (Give kind of work done during most lab KIND OF BUSINESS INDUSTRY 15 EDUCATION Spec ly Only highest grade completed) o(work'ng life. even if retired) Housewife Domestic _ D 16 FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME WHEN -,HIS COPY CARRLES THE RAISED SEAL OF THE NEBRASKA HEALFH�WAN SERVICES SYSTEM, R CER77FES THE BELOW TO BE A TRUE COPY OF THE ORiMULAECO .ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VIT/ 1pW87 891P7 !I, WHICH 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUL 2 8 2000 200010159 Aasisuwsr ISTRAR LINCOLN, NEBRASKA HEALIW AND AUNANAERVICIS SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND NM SER1NgpjE AND SUPPORT VITAL STATISTICS: - - CERTIFICATE OF DEA14+:i '` I DECEDENT NAME FIRS' MIDDLE LASI 22 SEX 1 D ,'�tF �F DFA - - - fH Af n (tat. lea; Ruth L. Hetrick Female July 21, 2000 4. CITY AND STATE OF BIRTH Ift nol in USA.. name counlryl 5a AGE Last Birthday I UNDER I YEAR UNDER t DAY 6 DATE OF BIRTH /Month. Dar Year) Lake Manawa, Iowa IY,I 77 October 30, 1722 Sb MOS DAYS 5c HOURS MINIS 7 SOCIAL SECURITY NUMBER 8, 8a. PLACE OF DEATH - 507 -16 -8102 HOSPITAL lnpatlent OTHER ❑ Nur, Hoene _______ —___. _... 27a DATE OF DEATH /MO Day YrI �28a DATE SIGNED /MO. Day Yr; 28o TIME OF DEATH ❑ ER Outpatient El Residence 8b FACILITY Name Of nol— Nution, give street and number/ St. Francis Medical Center ❑ DOA ❑ Other r$pecd, 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 9e COUNTY OF DEATH _ Grand Island I Yes X❑ Nd ❑ Hall STATE tllCTt^` 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER acluding Ztp Codel 9e MSIDE CITY LIMITS Nebraska Hall Grand Island 232 N.Ruby 68803 Yes No ❑ 10. RACE - le.g.. White. Black. American Indian 11. ANCESTRY le.g.. Italian. Mexican. German, etc) 12. K] MARRIED ❑WIDOWED 13 NAME OF SPOUSE fit wto give maiden name) etcl lScea (Specify) White American NEVER DIVORCED ❑ MARRIED Merwin Hetrick 14a USUAL OCCUPATION (Give kind of work done during most lab KIND OF BUSINESS INDUSTRY 15 EDUCATION Spec ly Only highest grade completed) o(work'ng life. even if retired) Housewife Domestic _ Elementary or SecondarY 10 121 College 1 , 10 16 FATHER -NAME FIRST MIDDLE LAST t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME Earnest Kiesel Stella Steuben 18. WAS DECEASED EVER IN US ARMED FORCES? , 19a INFORMANT - NAME - LY_es. — --v J I pt yes give war and dates of services) No Merwin Hetrick t9b 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 1:1 Burial F-1 RemdYal July 22, 2000 I Central Nebraska Cremation 22a FUNERAL HOME -NAME _ ltd CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATF _ Apfel- Butler - Geddes O Cremation ❑ Donation Gibbon, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 1 1 i " PART — r is y I (a) DUE TO. OR AS A CC Ibl Cq rq (c) IN VNI-Y Lint UAUDt HtH L1NC FVH lal. lot- ANU ICI) Interval between onset and deal, I SE REFERRED TO MEDICAL Interval between onset and death �AUTOPSY25 I Interval between ) onset and dean' OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related ART PART 111 IF FEMALE. WAS THERE A SE REFERRED TO MEDICAL PREGNANCY IN THE PAST 3 MONTHS�;[2� �AUTOPSY25 ER OR CORONER' (Ages lOSai Lies No s ❑ No 26a F1 Acc,oem L1 Undetermined 25b DATE OF INJU RY (Mo.. Day. Yr) 26c HOUR OF INJURY 6 DESCRIBE HOW INJURY OCCURRED M SoGde n Pending 26e INJURY AT WORK 261 PLACE OF INJURY - At home. farm. street. factory 26g LOCATION STREET OR R F D NO. Cliv OR TOWN Sin TI office building. etc 'Specify/ r, ❑ LJ Homicide Investigation Yes No _______ —___. _... 27a DATE OF DEATH /MO Day YrI �28a DATE SIGNED /MO. Day Yr; 28o TIME OF DEATH July 21,2000 'aw M 27b. DATE SIGNED (Mo.. Day. Yr) 27c TIME OF DEATH Aj '; 28, PRONOUNCED DEAD IM. Day. Yr I 28d. PRONOUNCED DEAD (Hour o July 21 2000 20pm)°ao M M g F _ a 27d To the best of my k th occurred the �me, d le a place and due to the .0 ° ° 28e On the basis of examination and or mvestigahon, in my odmon death - curred at causelsl state . ° the time, sate and place and due to the causelsl stated. ISI nature and Title ► V ISt nature and Title) No 29 DID TOBACCO USE CONTRIBUTE TO TH EATH? 30.a AS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED' ❑ YES ❑ NO UNKNOWN ❑ YES D_ RO ❑ YES P'NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) A. 809 N. Alpha Ave., Grand Island, NE. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo. Day Yr./ 6;r—ft JUL 2 7 2000 v - Lot Three (3), Block Twenty One (21), Packer & Barr's Second Addition m CD N 3 u► 2 co 3 .-r x