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WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RRc0FW' FAE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTId
<br />TH --
<br />E LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />SEP 7 2000 2000106 - �:�I
<br />ASI#AN13Td1Ic'ISltA
<br />LINCOLN, NEBRASKA �EALTHAND:Ni,9N S�RVIC�S` 4Y�TE
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN StRVIC£S F'MCN ANIt3U
<br />VITAL STATISTICS =
<br />CERTIFICATE. OF DFATU
<br />-- - -•�•� rind MIDDLE LAS'
<br />7 SEX 3 DATE OF DEATH
<br />Dennis Roy McGee
<br />Male Se
<br />4. CITY AND STATE OF BIRTH lfnofm USA.. name
<br />tember
<br />counlrY; Sa AGE Last e+rthtlav UNDER t YEAR
<br />UNDER 1 DAY 6. DATE OF BIRTH IMontb. Dav Year)
<br />Schuyler, Nebraska Yrs' Sb MGS DAYS
<br />63
<br />sc HO PIS Mws
<br />7 SOCIAL SECURi,v Nl1MHER - - ---
<br />— J a n u a r 12 1.937
<br />6a PLACE of DEATH
<br />TH
<br />__-
<br />_- - -.
<br />508-46-7120 HOSPITAL
<br />Inpatient OTHER ❑ Nurs,nq Homi,
<br />8b FACILITY -Name /Il not rnslifu(ioo. give street and number)
<br />ER Outpatient ❑ Residence
<br />St.Francis Medical Center ❑
<br />DoA ❑
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART ,I, IF FEMALE. WAS THERE A
<br />PART
<br />Other ,S,,,+n
<br />8c CI TV TOWN OR L:)C, TION -)F DEATH
<br />BC INSIDE CITY
<br />- --
<br />*
<br />LIMITS
<br />8e COUNTY
<br />OF DEA' H - - - -- -
<br />Grand Island
<br />Ye;
<br />a -
<br />9a. RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zip Code) 9e INSIDE CITY ITS
<br />Nebraska Hall Grand Island
<br />621 West 13th Yes ❑X No
<br />10 RACE - leg., White Black American Indian. 11. ANCESTRY Ie q Italian. Mexican. German. eta t2. �j MARRIED
<br />❑ WIDOWED 13 NAME OF SPOUSE /I/ wile. give maiden name/
<br />etcJ ISoeofyl (Specify)
<br />White American "EVER
<br />❑MAgRI D
<br />DIVORCED
<br />Ruth M. Mettenbrink_
<br />tna USUAL OCCUPATION ;Give knrdof wwk done during most 14b KIND OF BUSINESS INDUSTRY
<br />of work,eg /de. even d /el /red)
<br />I t 5 EDUCATION (Specify only Highest grade completed)
<br />C o n s t r u c t i o n Worker Construction
<br />Elementary or Secondary I0 -12) College n to, s l
<br />12
<br />16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Bert McGee Agnes Kment
<br />18 NJAS DECEASED EVER IN U S ARMED FORCES? t9a INFORMANT NAME
<br />_
<br />- - - --
<br />IYes nC. or k ) 1 II re, (1- war and dales of services)
<br />29 DID TOBACCO USE CONTRIBUTE TO THE D TH? 30
<br />_ No _ --!Ruth M. McGee
<br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO, CITY OR TOWN STATE ZIP(
<br />621 West 13th Street- Gram Tcla-A M -11 --t-
<br />20 EMRAI.M ER - $IGNA TUBE R LICENSE NO
<br />21a METH00 OF DISPOSITION
<br />1 21b DATE
<br />- - "- - "- -- - -- --
<br />21�c CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑Burial ❑Remo,,,
<br />Sept. 2 , 2000
<br />Central NE Cremation
<br />22a FUNERAL HOME NAME
<br />l 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATF
<br />All Faiths Funeral Home
<br />[A Cremation ❑Ddnangn
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIPI - --
<br />2929 South Locust Street, Grand Island, Nebraska 68801
<br />23 IMMRIATE CAUSE (ENTER ONLY O CAUSE PER LINE FOR raj Ib) . AND (cll -- _-
<br />PART Interval between onset and r..al+
<br />I ial
<br />DUE 70, OR AS A CONI&EQUENCE OF - Interval between onset and death
<br />DtlE TO. OR AS A CONSEQUENUEN CE OF `j �1 -- intErval t„sLwyen on,z mw a«o
<br />Ic)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART ,I, IF FEMALE. WAS THERE A
<br />PART
<br />24 AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />II � PREGNANCY IN THE PAST 3 MONTHS>
<br />EXAMINER OR CORONER''
<br />Ages 10 -541 Yes No
<br />Ves No
<br />r,
<br />Ves No IX
<br />126, 1 26b DATE OF INJURY IMO Day Yr_)
<br />26, HOUR OF INJURY "d. DESCRIBE HOW INJUR'+ _JC�URREO -- -IXYY-uuu
<br />� L_I ticadem ,yinele+,med �
<br />r l (
<br />M
<br />;- de _ P en dn4
<br />26e INJURY AT WORK 26f PLACE OF INJURY At home )arm street. factory
<br />o8ice build, ng. etc •Specdyl
<br />26q. LOCATION STREET OR R.F D NO !:ITV OR TOWN y7A7F
<br />omi
<br />Hcide Invesngaton Ves No ❑
<br />❑
<br />17a DATE OF DEATH IMO Day Yr.J
<br />cn
<br />28a. DATE SIGNED 'Mir Dav Yr; r281,i H TIME OF DEATH
<br />27b DATE SGNED Me Day W/ 27c TIME OF DEATH "'
<br />a J G
<br />z a
<br />Qm C l -� '""�/
<br />L) m -
<br />��
<br />M
<br />28c. PRONOUNCED DEAD !Mo. Day. Yr.J
<br />_____
<br />28tl PRONOUNCED DEAD /Hour,
<br />3 � ____ i i M
<br />L � � Z
<br />L-
<br />27d To
<br />M
<br />-- ---- _._ -_.- -
<br />28e. On the bases 01 examindUen and or investigation, m my Opinldn death UCCUrted at
<br />the Desf of m kn eath occurred at the time. date and o,ace and due to the -
<br />�. o J
<br />causelsl sta tl.
<br />the time date and place and due to the causelsl stated
<br />,
<br />ISI nalure and Title) 10 1 ��' �f�/ c 2_ •
<br />(SI nature and Title) 1,
<br />29 DID TOBACCO USE CONTRIBUTE TO THE D TH? 30
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO>
<br />30.D WAS CONSENT GRANTED'
<br />❑ YES ❑ NO UNKNOWN
<br />❑ YES R1 NO
<br />❑ YES © NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, Tvoe or print) "' - --
<br />an D. Crouch„ M.D.,,8Q0 Alpha St. Grand Island, Nebraska 68803
<br />32a PEGISTRAR ii— - -
<br />EXHIBIT "A"
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