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M C I 0 ITI > C!1 cn �C = n n = D M cn WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REIN FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTS SECTION_ WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE i4NLEY.S. COOPER OCT 17 2001 200400220 ASSISTAN3?ATAA'E !lEGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC£S.EINAMCE ANI}SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH - �f 11347 I DECEDENT - -NAME FIRST MIDDLE LAST 2 SEX -- ___ �3 J. \7E OF DEATH tl�. �.'t:: (t.rt 1 "ed /1 Audra Marie Hursh Femal October 07, 2001 o C-> V UNDER 1 YEAR UNDER I DAY 6 DATE OF BIRTH Month. Dav rear/ Chapman, Nebraska 94 April 04, 1907 9b MoG DAYS C A 7. SOCIAL SECURTIV NUMBER c' 'i buJding. etc / m T 8b FACILITY - Name /it not —Ni give sheet ano oumtterl St. Francis Medical Center DOA ❑ °i "" S'° 'I - - -_ _ 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS ee COUNTY OF DEATH Grand Island Yes I1z No ❑ Hall 9a RESIDENCE -STATE 9b COUNTY 9c CITY TOWN OR LOCATION 9C STREET AND NU MRFk 1 „ "n :.tiIDE _IT Nebraska Hall Grand Island o 10 RACE - (e g White. Black American Indian 1 t ANC ESTRV Ie q Italian. Me,t,can. German. etc, 12 E MARRIED ❑ WIDOWED i 13 NAME OF SPOUT F n wile Olive m 11011 13 1 -1 etc /'Spemtyl I Isreotyl �EJNEVER White i American _ MARRIED DIVORCED Floyd O. Hursh � I 14a USUAL OCCUPATION rGrve ktndol —A done dunng most 14b KIND OF BUSINESS INDUSTRY 'L t6 EDUCATION —1 Inestg ad- �ompletedl of working nfe even d retired/ School Teacher (Grand Island Public Scho -D n czi < 2 28c PRONOUNCED DEAD IMO Day, yr l 2 28tl PRONOUNCED DEAD /NOU O / /r( f f UT c7 W C.D .__..� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REIN FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTS SECTION_ WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE i4NLEY.S. COOPER OCT 17 2001 200400220 ASSISTAN3?ATAA'E !lEGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC£S.EINAMCE ANI}SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH - �f 11347 I DECEDENT - -NAME FIRST MIDDLE LAST 2 SEX -- ___ �3 J. \7E OF DEATH tl�. �.'t:: (t.rt 1 "ed /1 Audra Marie Hursh Femal October 07, 2001 d CITY AND STATE OF BIRTH Montle USA name country' 6a AGE Last Birthday UNDER 1 YEAR UNDER I DAY 6 DATE OF BIRTH Month. Dav rear/ Chapman, Nebraska 94 April 04, 1907 9b MoG DAYS 6e HOURS M1NS 7. SOCIAL SECURTIV NUMBER 8a PLACE OF DEATH 'i buJding. etc / 507 -24 -6133 HOSPITAL ® InpaTeN OTHER ❑ I'll e- 11 11 -,.. ❑ ER Outpatient ❑ Re; ue,rc.. 8b FACILITY - Name /it not —Ni give sheet ano oumtterl St. Francis Medical Center DOA ❑ °i "" S'° 'I - - -_ _ 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS ee COUNTY OF DEATH Grand Island Yes I1z No ❑ Hall 9a RESIDENCE -STATE 9b COUNTY 9c CITY TOWN OR LOCATION 9C STREET AND NU MRFk 1 „ "n :.tiIDE _IT Nebraska Hall Grand Island 11715 W. Charles 68803 YI 10 RACE - (e g White. Black American Indian 1 t ANC ESTRV Ie q Italian. Me,t,can. German. etc, 12 E MARRIED ❑ WIDOWED i 13 NAME OF SPOUT F n wile Olive m 11011 13 1 -1 etc /'Spemtyl I Isreotyl �EJNEVER White i American _ MARRIED DIVORCED Floyd O. Hursh � I 14a USUAL OCCUPATION rGrve ktndol —A done dunng most 14b KIND OF BUSINESS INDUSTRY 'L t6 EDUCATION —1 Inestg ad- �ompletedl of working nfe even d retired/ School Teacher (Grand Island Public Scho Elements y o ., _ Gulley °ll "` 5' (Ye, n0. pr unk no 19b INFORMANT 1715 Wes 20 EMBALMER SIC FIRST MIDDLE LAST 1 i MOTHER FIRST MlDtit MAIDEN SURNAME John P. Fishburn Ida Mae Van Cleave ER IN U S ARMED FORCES' :9a INFORMANT - NAME nl yes. gwe war arm dates pl services . Floyd Hursh MAILING ADDRESS STREET OR R F D NO CITY OR TOWN STATE ZIPI Charles Street, Grand Island, Nebraska 68803 f�l; LIC NSE NO 21, METHOD OF DISPOSITION 21b DATE 21, CE_MFIFR1_)- __:F %YT.)HV NAME -%' LYXG� - 111227 ❑X Burial Removal October 9, 200 Westlawn Memorial Park 22a FUNERAL HOME - NAME ltd CEMETERY OH CREMATORY LOCA LION :H IOWN STA ?= 1� A fel- Butler - Geddes Funeral Ho �]'_rema ` ❑ °o "a" 11 Grand Island, Nebraska 22b FUNERAL HOME ADDRESS ISTREET OR HE D NO ';ITV OR TOWN STATE. ZIP, III 1123 West Second Street, Grand Island, Nebraska 68801 -5899 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 11 ILI. AND X[, Interval between o".l _ PART I ' DUE TO OR AS n <;ONSECUENC OUENCE OF ncr ea netwe ? o ?s1 _ Ibl OUE TO OR AS A CONSEOUFNCE OF - I,etw n rs• Icl OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE WAS THERE A )_ T a AUTOP l 25 WAS CASE REFERRED 10 MEDICAL. PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER I i 11 (Ages 10541 Yes No Ves NI� a Ves Nu 26a 26b DATE OF INJURY 1Mo. Day. Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED iMl? Accident Undetermined M M Su,coe Pending 2 26e INJ 11RV AT WORK 2 26f PLACE O OF INJURY - - AI home farm , ,1reel f factory 2 26q LOCATION STREET OR R F D NO �I I Y OR TOWN nv I Homlcitle Iestigal,on y F_ ❑ ' 'i buJding. etc / /Specltyl 27a DATE OF DEATH lMo Day Y / 2 28a DATE SIGNED !Mr, Div vr, 28!. 'IMF OF DEATH v 2 27b DATE SIGNED, /MO. Day n 1 2 27c T TIME OF DEATH < < 2 28c PRONOUNCED DEAD IMO Day, yr l 2 28tl PRONOUNCED DEAD /NOU O / /r( f f ISM nature and Title) ► z L Signature and 29 DID TOBACCO USE CONTRIBUTE TO THE 9 THn 11 r 30.a HPS ORGAN OR TISSUE DONATION BEEN CONSIDERED' ❑ YES �' N❑ ❑ UNKNNIN YES JO -J 31 'JAME AND ADDRESS OF CERTIFIER IPHVSICIAN. CORONER S PHYSICIAN OR COUNTY AT TORNEY 7vpe or P, I'll Dr. Gordon J. Hrnicek, 729 Nortl2 Custer, Grand Island 132a REGISTRAR / s 300 WAS CONSENT GRANTED I Nebraska 68803 32b DATE FILED BY R EGIS I R A U 1Mo Day Vrl -- -(�- _❑1D� -- - M_ M d r N � o m o 0' s =) CD N N CD O � z O w o F-' rt w n� O G �J h- rt O zw a' rl m �:71 xw (U rl . H TA w Cn m n r 9 a a. r• rt r• O rt O rt (D rt i O I-n m a. H G7 H a. j'