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WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH A <br />SYSTE?4 IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL s <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS $ 0M <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />S ils801 R <br />DEC 2 7 2000 <br />ASsISTANT-StAIXAMNSTPoillf <br />LINCOLN, NEBRASKA HEALTH AND mdkAYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SlinciabiFiilAktAND.EIMORT <br />Amended August ' 24 , 2000 VITAL STATISTICS P I: <br />CERTIFICATE OF DEA"1'i, <br />t. DECEDENT • NAME FIRST MIDDLE ': LAST <br />Norman Eugene Mead <br />2. SEX " <br />Male e <br />`3: DATE OF DEATH /Month. Day Year). <br />July 28, 2000. <br />4 CITY AND STATE OF BIRTH IFnotin US A name country! <br />5a AGE Last BelbOay <br />UNDER. 1 YEAR <br />UNDER 1 DAY <br />6. TE OF BIRTH (Monet: Day Year) <br />Wood River, Nebraska <br />araC 69 <br />5b Mos DAYS <br />5c. HOURS ` MINS4, <br />1931 <br />7 SOCIAL SECURTIY NUMBER <br />505-34-8242 <br />8a PLACE OF DEATH <br />HOSPITAL: <br />X <br />❑ <br />❑ <br />Inpatient OTHER Nursing Home <br />ER Outpatient ❑ Residence <br />DOA ❑ olheriSpecily <br />8b FACILITY - Name /Ii not mslilulion, give street and numtarl. <br />BryanLGH Medical Center East <br />284 PRONOUNCED DEAD /Four/ <br />8c CITY TOWN OR LOCATION OF DEATH <br />Lincoln <br />80 INSIDE CITY LIMITS 8e. COUNTY OF DEATH <br />Yes (� No ❑ 1 Lancaster <br />9a RESIDENCE • STATE <br />Nebraska <br />9b COUNTY <br />►ge-� Hall <br />9c CITY. TOWN OR LOCATION <br />Wood River <br />90 STREET AND NUMBER larteludog Pip Cadet 9e. INSIDE <br />210 East 4th Street 1-68883I ,vs <br />CITY <br />E7 <br />LIMITS <br />No ❑ <br />10 RACE - (e.g. White. Black. American Indian.' <br />ISpectly) <br />W�A/c Itenglsh/Scotch <br />11. ANCESTRY le g Italian. Mexican. German, etc) <br />Specr 1s <br />12. <br />x <br />❑ <br />MARRIED <br />NEVER <br />MARRIED <br />in <br />■ <br />WIDOWED <br />DIVORCED <br />13 NAME OFSPOUSEI Or -de give Widen name) <br />pearl -mend -Reed <br />14a. USUAL OCCUPATION !Give ;and work' done during most <br />of wrong,* even Araeredl <br />Machinist <br />14b. KIND OF BUSINESS INDUSTRY - <br />Welding <br />15 EDUCATION (Specify only highest grade completed) - - <br />Elern n ry or Secondary 10-121 College 114 or 5-e <br />18: FATHER • NAME FIRST MIDDLE LAST <br />Arthur Mead <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Olga Dellert '= <br />18. WAS DECEASED <br />(Yes. no. or unk) <br />Yes I_ <br />EVER IN U S. ARMED FORCES? <br />(II yes give war and Oates of services) O l 12611951- <br />USMC 01/14/1954 <br />19a INFORMANT NAME <br />Pearl' Mead <br />95.. INFORMANT... <br />MAILING ADDRESS <br />(STREET OR R.5' D. NO.. CITY OR TOWN. STATE. <br />210 East 4th Street, Wood River, Nebraska 68883 <br />ALMER SIGNATURx BJLIC <br />1225 <br />22a FUNERAL -: NAME <br />Apfel Funeral Home <br />225 FUNERAL HOME ADDRESS. - (STREET OR R.F.D. NO.. CITY OR TOWN. STATE.. ZIP) <br />P.O. Box 126; Wood River, °Nebraska. 68883 <br />21 a METHOD OF DISPOSITION <br />OBurial ❑ Removal <br />❑ Cremation ❑ Donation <br />21b DATE <br />21c CEMETERY OR CREMATORY NAME' <br />08/01/2000 Wood River Cemetery <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Wood River, Nebraska <br />23. IMMEDIATE CAUSE <br />PART <br />lal <br />(ENTER ONLY ONE CAUSE PER LINE FOR Id (b). AND (cg Interval between Onset and clear', <br />DUE TO, ORAS A CONSEQUENCE OF971 hT, <br />•�.._ yr - " <br />Interval beetWOen Ons01 and death <br />DUE TO OR AS A CONSEQUENCE OF. <br />Interval between onset and 4880 <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to Me death but not related <br />PART <br />II <br />PART III. IF FEMALE. WAS THERE A <br />PREGNANCY M THE PAST 3 MONTHS? <br />(Ages 10-54) Yes n No ❑ <br />24 AUTOPSY <br />Yes ❑ No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER'+p <br />I J[( <br />Yes ❑ NO Tl <br />269. - <br />® Accident • Undetermined <br />® Suicide I Pending <br />Homicide Investigations <br />26b. DATE OF INJURY (Mo. Day Yr.) <br />26c. HOUR OF INJURY - <br />M <br />260. DESCRIBE HOW INJURY OCCURRED <br />26e :INJURY AT WORK <br />yea No ❑... <br />261 PLACE OF INJURY - Zit home farmgreet' factory <br />office building, etc. /Speceyl <br />269 LOCATION STREET OR R. F. D. NO CITY OR TOWN STATE <br />27a DATE OF DEATH (Mo. Day Yr.). : <br />28a.. DATE SIGNED Into Day. Yr) <br />28b TIME OF DEATH <br />1 6 <br />6 <br />gS_A <br />28c. PRONOUNCED DEAD (Mo DayV.) <br />284 PRONOUNCED DEAD /Four/ <br />g <br />27b DATE SIG into. ody. Yr/ <br />V ^�/may l <br />c IIA. :4i) JI/l/V <br />27c. TIME OF DEATH <br />` 1Z•I•S P .5E <br />.9 328e. <br />u 0 <br />On the basis of examination and or investigation in my opinion death occurred at <br />the bone. date and place and due to the causes) stated <br />(Signature and Title) ► <br />o a <br />27d To the best d my knowledge <br />` C0806(s1:stated <br />I (Signature and Title) ► <br />at <br />ime, date and place and due to the <br />29. DID TOBACCO USE: CONTRIBUTE TO THE DEATH? \ <br />_❑ YES ❑ NO NUNKNOWN <br />30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />❑ VES (J�( NO <br />30.5 WAS CONSENT <br />GRANTED? <br />®.YES. <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type of PNnU <br />James Wudel M.D. <br />32a REGISTRAR <br />00 Sofh <br />th Stre_et., Suite 800• Lincoln Nebraska._�85011585 <br />32D. DATE FILED BY EGISTWpR <br />AUG10 1's�r <br />