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r .. WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH Aqq_ -i QiAIfFS! SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL NBC_ _ .fl THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA77S71t =_ H THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE _ 2 0 0110 3 0 3 MAR 2 4 2000 ASS►STAkt -_$ E AR LINCOLN, NEBRASKA HEALTH AND HUMAN S&R S-'I STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIT ANCE VITAL STATISTICS CERTIFICATE OF DEATH 11 DECEDENT NAME FIRST MIDDLE LAST 2. SEX • 3 DATE OF DEATH /Month flay Year! Rose Mary Jares Female March 20, 2000_ 4 (ITV AND STATE OF BIRTH Ill noun USA name country) Sa AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAN' 6. DATE OF BIRTH !Month. Dav Year) Yral 26e. INJURY AT WORK 5b Mos DAYS Sc HoDRS MINS Elm Creek, Nebraska 90 office budding. e1c iSpecity) January 12, 1910 7 SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL IN Inpatient OTHER ❑ Nursing Home 506 -14 -3837 27a DATE OF DEATH wo. Day. ycl ❑ ER Outpatient ❑ Residence Bb FACILITY Name 111 not �nslnution. give street and number) St. Francis Medical Center ❑ DOA ❑ OthertSpenty, 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes [R No ❑ Hall 9A RESIDENCE STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Codei 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 212 E. 17th St. I Yes ®Nb ❑ 70 RACE le q., While. Black. American Indian. I1. ANCESTRY le q.. Italian. Mexican. German, etc) 12. a MARRIED ❑ WIDOWED 13 NAME OF SPOUSE I)t wde give maiden namel etc Sceclryl White (Speary) American I NEVER DIVORCED Johnnie Jares 28e On the basis of examination and or Investigation. In my opinion death occurred at y _causelsi stated. MARRI 14a USUAL OCCUPATION d3we bndut work done during most t41b KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpeoty only highest grade completed) _ Elementary or Secondary (0 -12) College ! 1 : or S of worA,ng Ide. even if retrredl 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Presser Dry Clea ing 8th Grade _ 16 FATHER NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME John Demuth Mary Unknown iYes hk d Ves I've war and dales Of services! No - - - - -- j Johnnie Jares 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN. STATE. ZIPI 212 E. 17th St., Grand Island, Nebraska 68801 _ 20 - ALMER - SIGNATURE B LICENSE NO 1 21a METHOD OF DISPOSITION 21b. DATE 21 c CEMETERY OR CREMATORY NAME 3 © Burial ❑ Removal l Mar. 24 2000 Westlawn Memorial Park 22a FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE _Livin stop- Sondermann F.H. 1:1 Cremation ❑Donallon Grand Tclnnd- Nahracka 22b FUNERAL HOME ADDRESS fSTREET OR R.F.D. NO CITY OR TOWN STATE. ZIPI 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CA SE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl. AND (cl) PART \ A ^ I al 1 DUE TO, OR AS A CONSEIDUENCE OF Ib DUE 70. OR AS A CONSEQUENCE OF I tnterval them en onset and death Interval between onset bnd deallh I Inte —I between onset and dealt, OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not re(aled PART III IF FEMALE WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDiCAt "' PART PREGNANCY IN THE PAST 3 MONTHS %' E %AMINEH O RONER IA es 10 -54 Yes No Yes NO Yes No A9 I 26a 26b DATE OF INJURY (MO. Dav Yr.l 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED f( l j Undeo—ni,cl A—den I_ M n Smotle Pendlnq 26e. INJURY AT WORK 26f PLACE OF INJURY - At home, farm. street. factory 26g LOCATION STREET OR R.F D NO CITY OR 1 QN /N STATF HOrh•6de Invest'gation Yes ❑ ❑ office budding. e1c iSpecity) No 27a DATE OF DEATH wo. Day. ycl 28a DATE SIGNED (Mo.. Day Yr I 281b TIME OF DEATH I LCJ aN i 4 < M v"-, 27b DA (Mo.. Day Yrl 27c TIME OF DEATH 28C PRONOUNCED DEAD (Mo Day, Yi1 28d. PRONOUNCED DEAD IHourl E O cTn i r � Z� ZCJ� M ° ° M IV 27d Tome best of my kno ge. death curre��gaaal��Tthe T e. date and place and due tome 28e On the basis of examination and or Investigation. In my opinion death occurred at y _causelsi stated. }{ the time, date and place and due to the cause(s) slated. ISI nature and Title) 1, .� )SI nature and Title ► 29 DID TOBACCO USE CONTRIBUTE TO TH EATH7 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 31) b WAS CONSENT GRANTED? ❑ YES ❑ NO 0 UNKNOWN L ❑ YES '� NO [�� (" ❑ YES I •NO S''� 31 NAME AND ADDRESS OF CERTIFIER fP "VSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) If 32a REGISTRAR 32b DATE FILED BY REGISTRAR (W, Dy. YYI ) . wwvf; _ -._ GI - ______111 SL _1000