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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AWHUMAN SERVICES
<br />SYSTEM Cf CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL- RE¢QRD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 5tAl*I1C$ SEG1VNi WHICH Is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />DEC 2 11999 -?004/0001S _ LEY -COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH_AND'HUM&N SERVICES- SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER.VC ANCE,*ND SUPPORT
<br />vTTAL STATISTICS 'w
<br />CFRT1F1rATF OF nPAT W-__^ F'
<br />t. DECEDENT - NAME FIRST MIDDLE LAST
<br />2, SEX
<br />A
<br />nn
<br />Male
<br />December 8, 1999
<br />4. CITY AND STATE OF BIRTH td nct n USA.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAV
<br />6. DATE OF BIRTH tMdrdit. Day. Year)
<br />MOS I DAYS
<br />Sc.HOURS' MINS
<br />M
<br />=
<br />D
<br />7, SOCIAL SECURTIY NUMBER
<br />Sa. PLACE OF DEATH
<br />506 -30 -2546
<br />HOSPITAL Lj Inpatient OTHER ❑ Nursing Home
<br />® ER Outpalient ❑ Residence
<br />lib. FACILITY - Name /l7not msafutbn. give sheer ard number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Sidecdv,
<br />M
<br />_
<br />lie. COUNTY OF DEATH
<br />Grand Island
<br />Yea © No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />m
<br />9c, CITY. TOWN OR LOCATION
<br />9d. STREUA_ND NUMBER (IncWdlrlp Zip Coall - '-
<br />9a yhBILE 6FW- {h;ITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1630 Jerry Dr. 68803
<br />yea ® No ❑
<br />10. RACE - (e.g., Whte. Black. American Indian,
<br />C=)
<br />12.]E MARRIED ❑ WIDOWED
<br />n
<br />etc .l ISpecilyl4lWhite
<br />©
<br />!�
<br />Donna Murray
<br />14a. USUAL OCCUPATION (Give kind of *wk dome during most 14b.
<br />s
<br />C>
<br />Swift & Co.
<br />r F
<br />{�
<br />D
<br />Irwin Crosser F
<br />Gladys M. Miller
<br />18 . WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />r.- -4
<br />`�
<br />D
<br />M
<br />1 Donna Crosser
<br />Cp
<br />1630 Jerry Drive Grand Island NE 68803
<br />cn
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />5
<br />x
<br />j
<br />12/11/99
<br />__4
<br />C
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ❑ Donakon
<br />Wood River NE
<br />22b. FUNERAL HOME ADDRESS (STREET Or) R.F.D. NO.. CITY OR TOWN. STATE, ZIP( -
<br />411 West 11th P.O. Box 126 Wood River NE 68883
<br />M
<br />PART I
<br />I (a) Cardiac arrest unknown
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />CD
<br />DUE TO OR AS A CONSEQUENCE OF: Interval between onset an! death
<br />200400015
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />^\
<br />CD
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />Yes 0 No
<br />26a
<br />26b. DATE OF INJURY I ... Day. Yr.)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident 0 Undetermined
<br />M
<br />D Suicide F-1 Pending
<br />260. INJURY AT WORK
<br />�r
<br />2Fg. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide mvesegakon
<br />❑❑
<br />Yes No
<br />❑
<br />1
<br />o
<br />27a. DATE OF DEATH (Mo. Day, Yr)
<br />26a. DATE SIGNED (Mo. Day. Yr)
<br />26b. TIME OF DEATH
<br />to
<br />,k
<br />Y
<br />27b. DATE SIGNED /Ab.. Day. n.l
<br />27c. TIME OF DEATH
<br />2 &. PRONOUN ED DEAD /MO.. troy yr/
<br />L. PRONOUNCED DEA (HOUII
<br />O
<br />M
<br />¢
<br />M
<br />27d. To the best of my knowledge. death occurred at the ems. date and place and due to the
<br />26e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />causes) stated,
<br />v 6
<br />the lime. date and pace W csuae(a) stated.
<br />(Signature and TOO
<br />S' t18e and Tilt
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />W SENT GRANTED?
<br />YES Fl NO 12 UNKNOWN
<br />1:1 YES [0 NO
<br />❑ YES � NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print]
<br />Ellen L TotzkQ, Hall County Attorney, 117 E 1st Grand Island, NE 6881
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (W... Day. Yr.)
<br />DEC 201999
<br />r
<br />W
<br />' ^
<br />V •
<br />z
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AWHUMAN SERVICES
<br />SYSTEM Cf CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL- RE¢QRD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 5tAl*I1C$ SEG1VNi WHICH Is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />DEC 2 11999 -?004/0001S _ LEY -COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH_AND'HUM&N SERVICES- SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER.VC ANCE,*ND SUPPORT
<br />vTTAL STATISTICS 'w
<br />CFRT1F1rATF OF nPAT W-__^ F'
<br />t. DECEDENT - NAME FIRST MIDDLE LAST
<br />2, SEX
<br />3. DATE OF DEATH /Month. Day Year)
<br />Wayne LaVelle Crosser
<br />Male
<br />December 8, 1999
<br />4. CITY AND STATE OF BIRTH td nct n USA.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAV
<br />6. DATE OF BIRTH tMdrdit. Day. Year)
<br />MOS I DAYS
<br />Sc.HOURS' MINS
<br />Wood River, Nebraska
<br />IYrs1 72 Sb.
<br />January 25, 1927
<br />7, SOCIAL SECURTIY NUMBER
<br />Sa. PLACE OF DEATH
<br />506 -30 -2546
<br />HOSPITAL Lj Inpatient OTHER ❑ Nursing Home
<br />® ER Outpalient ❑ Residence
<br />lib. FACILITY - Name /l7not msafutbn. give sheer ard number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Sidecdv,
<br />Sc . CITY TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />lie. COUNTY OF DEATH
<br />Grand Island
<br />Yea © No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c, CITY. TOWN OR LOCATION
<br />9d. STREUA_ND NUMBER (IncWdlrlp Zip Coall - '-
<br />9a yhBILE 6FW- {h;ITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1630 Jerry Dr. 68803
<br />yea ® No ❑
<br />10. RACE - (e.g., Whte. Black. American Indian,
<br />11. ANCESTRY le.g.. Italian. Mexican, German, atc)
<br />12.]E MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE to wife. give maiden name/
<br />etc .l ISpecilyl4lWhite
<br />(S tifyl�eini /En 11Sh
<br />I
<br />E] NEVER DIVORCED
<br />Donna Murray
<br />14a. USUAL OCCUPATION (Give kind of *wk dome during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />115. EDUCATION (Specify only ti hest grade completed(
<br />of working We,, even it reared)
<br />Laborer /scaler
<br />Swift & Co.
<br />Ekr9eg(ary or Secondary 10121 College 11.4 or i•I
<br />�L
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Irwin Crosser F
<br />Gladys M. Miller
<br />18 . WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes r c 'r u-k.( ; (11 yes. give war and dales of serviced
<br />Yes 1952 -1954 Korean
<br />1 Donna Crosser
<br />19c. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP(
<br />1630 Jerry Drive Grand Island NE 68803
<br />20. EMBALMER - SIGNATURE d LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />® Burial ❑ Removal
<br />12/11/99
<br />Cameron Cemetery
<br />225 FtJNEPFAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ❑ Donakon
<br />Wood River NE
<br />22b. FUNERAL HOME ADDRESS (STREET Or) R.F.D. NO.. CITY OR TOWN. STATE, ZIP( -
<br />411 West 11th P.O. Box 126 Wood River NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl, AND (c)) Interval between onset and death
<br />PART I
<br />I (a) Cardiac arrest unknown
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />DUE TO OR AS A CONSEQUENCE OF: Interval between onset an! death
<br />(c) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />Yes 0 No
<br />26a
<br />26b. DATE OF INJURY I ... Day. Yr.)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident 0 Undetermined
<br />M
<br />D Suicide F-1 Pending
<br />260. INJURY AT WORK
<br />261. PLACE OF INJURY - At M ,farm. street. factory
<br />o ice building, etc /Speciryt
<br />2Fg. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide mvesegakon
<br />❑❑
<br />Yes No
<br />❑
<br />1
<br />27a. DATE OF DEATH (Mo. Day, Yr)
<br />26a. DATE SIGNED (Mo. Day. Yr)
<br />26b. TIME OF DEATH
<br />,k
<br />Y
<br />27b. DATE SIGNED /Ab.. Day. n.l
<br />27c. TIME OF DEATH
<br />2 &. PRONOUN ED DEAD /MO.. troy yr/
<br />L. PRONOUNCED DEA (HOUII
<br />8
<br />M
<br />¢
<br />M
<br />27d. To the best of my knowledge. death occurred at the ems. date and place and due to the
<br />26e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />causes) stated,
<br />v 6
<br />the lime. date and pace W csuae(a) stated.
<br />(Signature and TOO
<br />S' t18e and Tilt
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />W SENT GRANTED?
<br />YES Fl NO 12 UNKNOWN
<br />1:1 YES [0 NO
<br />❑ YES � NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print]
<br />Ellen L TotzkQ, Hall County Attorney, 117 E 1st Grand Island, NE 6881
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (W... Day. Yr.)
<br />DEC 201999
<br />d ar - - -v
<br />
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