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�o <br />M <br />C <br />I- <br />WHEN THIS COPY CAI RTES THE RAISED SEAL Of3;THE NEBRAS U <br />SYSTEII4 IT CERTFES THE BELOW TO BE A TRUE COPY OF THE, <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DNOVF /920 200010626 A�YS <br />rsrANT stAc: <br />LINCOLN, NEBRA� HEALTH�RIAC"�S$1 OF NEBRASKA- DEPARTMENT OF HEALTH AND S CE AI5 <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />O <br />C7 <br />rTj <br />cn <br />W <br />h 0 <br />Blanche ' Carlson e <br />•Sa <br />C) --1 <br />CZ <br />G D <br />506 -28 -8948 HOSPITAL HOSPI. ❑ Inpatient OTHER ® Nursing Home <br />8b. FACILITY - Name (Ifnot mstilution. give street and number) ❑ ER Outpatient ❑ B -mince <br />Wedgewood Care Center ❑ DOA ❑ <br />m <br />o <br />o <br />-n <br />o <br />Hall <br />CD <br />9d. STREET AND NUMBER (Includdng Zp G.ude) 9e INSIDE GI7V LIMITS <br />Nebraska all Grand Island <br />4216 Utah Ave.68803 yes ® "n❑ <br />10. RACE - (e.g., While. Black. American Intlian. <br />r D <br />O <br />Cn <br />etc .I (Specify) <br />white <br />;K <br />O" <br />14a USUAL OCCUPATION iG,ve kind of work done during most lob <br />of working Me. even it rehredl <br />cn <br />a) <br />cn <br />Homemaker <br />ucucverv, ry 1 tIRST MIDDLE - - <br />LAST 2 SEA ---- -- 3 DATE OF DEAT'r, ,Ll,­lh i);t <br />Blanche ' Carlson e <br />•Sa <br />4. CITY AND STATE OF BIRTH 111 not in USA. name cournry : _ <br />AGE -Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH IMOnNr Dav Year, <br />lyrs I 56. MOS DAYS 5c. HOURS MINS <br />Loup City, Nebraska 89 <br />Jul 28 1911 <br />7. SOCIAL SECURTIY NUMBER - .- - -.... <br />8a PLACE OF DEATH <br />506 -28 -8948 HOSPITAL HOSPI. ❑ Inpatient OTHER ® Nursing Home <br />8b. FACILITY - Name (Ifnot mstilution. give street and number) ❑ ER Outpatient ❑ B -mince <br />Wedgewood Care Center ❑ DOA ❑ <br />Other /Spec/,, _ <br />8c CITY. TOWN OR LOCATION OF DEATH <br />84 INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />yas ® No ❑ <br />Hall <br />9a. RESIDENCE - STATE 9b COUNTY 9c. CITY TOWN OR LOCATION <br />9d. STREET AND NUMBER (Includdng Zp G.ude) 9e INSIDE GI7V LIMITS <br />Nebraska all Grand Island <br />4216 Utah Ave.68803 yes ® "n❑ <br />10. RACE - (e.g., While. Black. American Intlian. <br />11. ANCESTRY (eg. Malian. Mexican. German, etc) <br />12. ❑ MARRIED ® WIDOWED <br />13 NAME OF SPOUSE Of wde give maiden name) <br />etc .I (Specify) <br />white <br />ISpecdyl <br />American <br />NEVER <br />MARR DIVORCED <br />14a USUAL OCCUPATION iG,ve kind of work done during most lob <br />of working Me. even it rehredl <br />KIND OF BUSINESS INDUSTRY <br />15 EDUCATION Specsy, only highest grade completed) <br />__- <br />Elementary or Secondary 10.12) College 14 w S- <br />12 <br />Homemaker <br />domestic <br />16. FATHER -NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Hans Johnson <br />Mary Bloom uist <br />18. WAS DECEASED <br />EVER IN U.S ARMED FORCES' <br />fga. INFORMANT -NAME -- <br />(Yes. no or unk.) <br />(if yes. give war and dales of servrcesl <br />no <br />Roger Mueller <br />19b. INFORMANT MAILING ADDRESS (STREET OR R F D NO. CITY OR TOWN: STATE. ZIP) - <br />617 Plum Road Grand Island Nebraska 68801 <br />20.E AALLMME/R - S URE 8 EE%NSE NO <br />21a METHOD OF DISPOSITION <br />21b. DATE - - <br />_ <br />21c CEMETERY OR CREMATORY NAME <br />/d7j <br />OBurial ❑Removal <br />Nov.S 2000 <br />Palmer Cemetery <br />a. FUNERAL HOME - NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />All Faiths Funeral Home <br />❑Gemahon 1:1 Donato, <br />Palmer. Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D NO CITY OR TOWN. STATE. ZIP) - -- __ <br />2929 S. Locust St. Grand Island Nebraska 68801 <br />23. IMMEDIATE CAUSE - - -- <br />ENTER ONLY ONE CI AU /SE PER LINE FOR (a). (b). AND Icl <br />l llnn7 teW r val b"etw- enene onese7 <br />PART t <br />�J <br />a) <br />"I <br />DUE T0. RASA CON9EQuENCE OF )' /at,)'- Interval between onset an/ / tJ, A ,/ V avam <br />DUE TO. OR ASfCt5NSEQUENCE OF Interval between onset ann seem <br />(c) <br />OTHER NIFICANT CONDITIONS Conditions contributing to the death but not relaled PART <br />PART <br />III IF FEMALE. WAS THERE A <br />2a AUTOPSY <br />25 WAS CASE REFERRED 10 MEDICAL <br />11 I , _ PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />q� <br />�/� (Ages <br />10 -Sd) Ye No <br />Yes No <br />Yes No <br />26a. <br />26b. DATE OF INJURY JMo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED - <br />Accident F-] Undetermined <br />M <br />Suicide D Pending <br />26I PLLACE OF INJURY - ,I home . farm. street, factory <br />bustling. etc )Spec sly ) <br />26g. LOCATION STREET OR BE D. NO CITY OR TOWN STATE <br />❑O81ce <br />Homicide Investigation <br />=e,N <br />27a. DATE OF DEATH tMo. Day Yr) <br />28a. DATE SIGNED /Mo Day YO <br />28b TIME OF DEATH <br />November 2 2000 <br />M <br />�a, <br />4 <br />27b. DATE SIGNED /Mo. Day Yr) <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD lMo. Day. Yr/ <br />28d PRONOUNCED DEAD 'Ho,, <br />_ `� <br />O M <br />M <br />5 g6 <br />$' u <br />27tl. To the best of my knowledge a al the time, dale and place Arid due to the <br />28e. On the basis of examination andror investigation, m my opinion death occurred a1 <br />~ <br />.°. § ° <br />cause(sl stated . /��'�'/ /� <br />1. 1. (Signature and Title) ► '/"1' <br />B <br />the time, date and place and due to the cause(s) slated. <br />, (Sr nature and Title) ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 36a <br />HIM ORGAN OR TISSUE DONATION BEEN CONSIDERED' <br />30.b WAS CONSENT GRANTED' <br />❑ YES ❑ NO UNKNOWN <br />❑ YES JZ NO <br />❑ <br />YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER -S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) - <br />Richard Frueblina M.D. <br />32a. REGISTRAR <br />32b. DATE FILED BV REGISTRAR tMO.. Day. Yr/ <br />NOV 8 2000 <br />v <br />tAc <br />