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Recorder: Lots Seven (7) and Nine (9), Block Twenty -Three (23),
<br />University Place Addition, City of Grand Island, Hall County, Nebraska.
<br />WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, RCERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE0bIW_A FILE- KITH + �y
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS Z N,_ lCkI S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. —
<br />DATE OF ISSUANCE 200109780
<br />14UG 16 2001 - sr*w � C0 =
<br />ASS1I1�,8TATE Rt,�slfi/Ii�=
<br />LINCOLN, NEBRASKA HEALTH AND HtMA1t$VMCE5- Y%rEIt°
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYiC7EgFI2Fi Xi 'SUPPMRT (�
<br />VITAL STATISTICS
<br />CERTI IF CATE OF DEATH = _01 0 6 5 `/� r `/j
<br />�'
<br />:EDENT - NAME FIRST
<br />MIDDLE LAST
<br />2 SEX
<br />C1
<br />n
<br />Ella Oliver
<br />o
<br />c? cr
<br />O
<br />a
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />=
<br />y
<br />5c HOURS MINS
<br />Grand Island, Nebraska
<br />(Yrsl 69
<br />September 13, 1931
<br />co
<br />Acc, Undetermined
<br />1Sutelde
<br />Ba PLACE OF DEATH
<br />C
<br />fl
<br />❑ Pending
<br />HOSPITAL ❑ Inpatient
<br />OTHER ® Nursing Home
<br />505-36-8754
<br />CD
<br />CILITY - Name /)l nol mslilulion, give sfreel and number)
<br />St. Francis Skilled
<br />Care
<br />❑ DOA ❑ Otherrspecdvv
<br />rY TOWN OR LOCATION OF DEATH
<br />:1-3 A
<br />�v
<br />-± rte:
<br />O
<br />Yr.)
<br />® ❑
<br />N
<br />Hall
<br />c'
<br />r �'
<br />O
<br />9b COUNTY
<br />M
<br />9c. CITY. TOWN OR LOCATION
<br />Vqi
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />�}
<br />N
<br /><��
<br />1918 N. Howard 68803
<br />C
<br />ICE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY leg. Italian. Mexican. German. elcl
<br />72. ❑ MARRIED
<br />® WIDOWED
<br />13. NAME OF SPOUSE dN wife, give maiden camel
<br />1
<br />O
<br />American
<br />F--&
<br />DIVORCED
<br />Myron Oliver
<br />ISUAL OCCUPATION /Give kind o /work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completed
<br />Elementary or Secondary (0 121 College 11 4 or 5-I
<br />J working file, even i /resredl
<br />30.b WAS CONSENT GRANTED'(
<br />F1 YES 1:1 NO N UNKNOWN
<br />Housewife
<br />❑ YES ❑ NO
<br />Domestic
<br />.'
<br />8
<br />r7
<br />t 7 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />O
<br />Rauert
<br />Frieda Ber holz
<br />AS DECEASED EVER IN U. S. ARMED FORCES?
<br />19a.INFORMANT -NAME
<br />s. no. or unk J (if yes. give war and dates of services)
<br />No
<br />co
<br />-
<br />_�
<br />CD1�
<br />1=
<br />CIO
<br />CD
<br />Recorder: Lots Seven (7) and Nine (9), Block Twenty -Three (23),
<br />University Place Addition, City of Grand Island, Hall County, Nebraska.
<br />WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, RCERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE0bIW_A FILE- KITH + �y
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS Z N,_ lCkI S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. —
<br />DATE OF ISSUANCE 200109780
<br />14UG 16 2001 - sr*w � C0 =
<br />ASS1I1�,8TATE Rt,�slfi/Ii�=
<br />LINCOLN, NEBRASKA HEALTH AND HtMA1t$VMCE5- Y%rEIt°
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYiC7EgFI2Fi Xi 'SUPPMRT (�
<br />VITAL STATISTICS
<br />CERTI IF CATE OF DEATH = _01 0 6 5 `/� r `/j
<br />�'
<br />:EDENT - NAME FIRST
<br />MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH ;Month Day Yearl
<br />Evelyn
<br />Ella Oliver
<br />Female°
<br />June 10, 2001
<br />Y AND STATE OF BIRTH llf not m U S.A.. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH /Mont. Day. Yearl
<br />Sb Mos DAYS
<br />5c HOURS MINS
<br />Grand Island, Nebraska
<br />(Yrsl 69
<br />September 13, 1931
<br />AAL SECURTIY NUMBER
<br />Acc, Undetermined
<br />1Sutelde
<br />Ba PLACE OF DEATH
<br />M
<br />❑ Pending
<br />HOSPITAL ❑ Inpatient
<br />OTHER ® Nursing Home
<br />505-36-8754
<br />❑ ER Outpatient ❑ Residence
<br />CILITY - Name /)l nol mslilulion, give sfreel and number)
<br />St. Francis Skilled
<br />Care
<br />❑ DOA ❑ Otherrspecdvv
<br />rY TOWN OR LOCATION OF DEATH
<br />Bd INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />Yr.)
<br />® ❑
<br />1(0 101b
<br />Hall
<br />Yes No
<br />r �'
<br />SIDENCE - STATE
<br />9b COUNTY
<br />M
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />/, hham�-.++
<br />1
<br />Grand Island
<br />1918 N. Howard 68803
<br />Yes ® No❑
<br />ICE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY leg. Italian. Mexican. German. elcl
<br />72. ❑ MARRIED
<br />® WIDOWED
<br />13. NAME OF SPOUSE dN wife, give maiden camel
<br />A 1Specufyl White
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />American
<br />NEVER
<br />MAR
<br />DIVORCED
<br />Myron Oliver
<br />ISUAL OCCUPATION /Give kind o /work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completed
<br />Elementary or Secondary (0 121 College 11 4 or 5-I
<br />J working file, even i /resredl
<br />30.b WAS CONSENT GRANTED'(
<br />F1 YES 1:1 NO N UNKNOWN
<br />Housewife
<br />❑ YES ❑ NO
<br />Domestic
<br />8
<br />ITHER - NAME FIRST MIDDLE LAST
<br />t 7 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Clarence
<br />Rauert
<br />Frieda Ber holz
<br />AS DECEASED EVER IN U. S. ARMED FORCES?
<br />19a.INFORMANT -NAME
<br />s. no. or unk J (if yes. give war and dates of services)
<br />No
<br />Rodney Oliver
<br />-
<br />4,UMMA.I MNIUrvu NVV . -i—i Un n.n —, Ulr Vn 1V 11,J I nlc. urn
<br />218 E. 14th, Grand Island, NE. 68801
<br />ALMER - SIGNATURE 8 LICENSE NO ) / / 21 a. METHOD OF DISPOSITION 21 b. DATE 2 . CEMETERY OR CREMATORY NAME
<br />///1l J /y
<br />�,.� �i /�.� ®Burial ❑Removal June 13, 2001 Westlawn Memorial Park
<br />L INFRAI 4AMF . NAME 21d. CEMETERY R CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes I ❑Cremation ❑Donautln I Grand Island, NE.
<br />'UNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b(. AND (cp I Interval between onset and deam
<br />AT
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and neat
<br />I
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and deam
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />,AT PREGNANCY
<br />IN THE PAST 3 MONTHS,
<br />EXAMINER OR CORONER?
<br />I Co
<br />PI>
<br />(Ages 10 -54( Yes 0 No
<br />Yes M No X1
<br />Yes No
<br />26b DATE OF INJURY (pDay.
<br />26c. HOUR OF INJU RY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Acc, Undetermined
<br />1Sutelde
<br />M
<br />❑ Pending
<br />26e. INJURY AT WORK
<br />nding INJURY
<br />t homl . farm. street. factory
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑ ❑
<br />l
<br />Yes NO
<br />27a. ATE OF DEATH (MO. Day. YrJ
<br />28a DATE SIGNED /Mo. Day
<br />Yr.)
<br />28b TIME OF DEATH
<br />1(0 101b
<br />4
<br />r �'
<br />M
<br />27b. DATE SIGNED /Mo.. Day. Yr 1
<br />21, TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo... Day, Yr.)
<br />28d. PRONOUNCED DEAD lHourl
<br />I O!
<br />/, hham�-.++
<br />1
<br />!B9
<br />lY
<br />V I J M
<br />_
<br />° ,
<br />M
<br />270. TO the tMSt 01 my knowledge. death occurred at the time, date and place and due 10 the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />cluselsl stated x/1/1
<br />S
<br />the lime. dale and place and due to the caueelsl stated.
<br />(I' I
<br />ISI nature and Title ►
<br />(Signature and Title ►
<br />10 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.8 HAS ORGAN OR TISSUE DONATION CONSIDERED?
<br />30.b WAS CONSENT GRANTED'(
<br />F1 YES 1:1 NO N UNKNOWN
<br />[BEEN
<br />11 YES 17V NO
<br />❑ YES ❑ NO
<br />IAMIc ANU AVUMCJJV VC IIYICn Ir JIVI VV V Jrni JiVlnry u�VVUrvi•nliVnivcri rrypew rrrnr,
<br />New e�y�bcK r';,y1MD2444 Faidley Ave., Grand Island, NE. 68803
<br />REGISTRAR 32b DATE FILED BY REGISTRAR /MO.. Day. Yr)
<br />4 r I ( 11111 1 (1 HAI
<br />6. Inc?
<br />
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