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WHEN INS COPYCARRAES TIE RAISED SEAL OF THE NEBRASKA HEALTH ANA _ ES
<br />SYSTEM, IT CERTIFES TtE BELOW TO BE A TRUE COPY OF THE ORIGINAL � �.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISi�$ 1 - em
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE /� (� V h-�-
<br />MAR 6 20U3 v V V N L
<br />ASS/ST�{IfF- -S'i�: '- �_ � TAR;;-
<br />LINCOLN, NEBRASKA HEALTH ANDHUIN�kLIC SY�fA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICB- 0T 14' A-AM- i1PPORT
<br />VITAL STATISTICS = 0 3 02425
<br />C'F F. .RTTFTrAT OF DRATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Mont. Day Year)
<br />Ardith LeIla Kokes
<br />Female
<br />March 3, 2003
<br />4. CITY AND STATE OF BIRTH
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH /Monts. Day. Year)
<br />MOS I DAYS
<br />5c. HOURS' MINS
<br />Hampton, Nebraska
<br />(Yrs.) 75 5b,
<br />January 31, 1928
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -30 -2329
<br />HOSPITAL: © Inpatient OTHER ❑ Nursing Home
<br />ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /Moot institution, give street and number/
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specdy,
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />4
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I Yes [j No ❑
<br />Hall
<br />8a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Inctudng zip code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />L
<br />S
<br />11. ANCESTRY fe.g_ Italian. Mexican, German, etcl
<br />12. a MARRIED ❑ WIDOWED
<br />C
<br />etc.) (Specify)
<br />White
<br />Pat;
<br />ISPat; 1
<br />n=
<br />Edwin Kokes
<br />o
<br />o
<br />c
<br />(\
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10- t 21 Cdlege 11 -4 or 5.I
<br />z
<br />tician
<br />01
<br />1 Year
<br />r s�
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />z- a
<br />N
<br />C3.
<br />\r
<br />nk.) (If yes, give war and dates of services(
<br />-=
<br />C�
<br />D
<br />0
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />3210 E. Gregory, Grand Island, Nebraska 68801
<br />20. LMER - SIGNATURE 8 LICENSE NO.
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />T
<br />. �a
<br />Q-•� �/I 44
<br />_j rn
<br />o
<br />N
<br />22a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />rn
<br />❑Crematim ❑Donalich
<br />Hastin gs, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Is). III). AND (q) Interval between onset and death
<br />✓pART �
<br />I • {� I� WSJ
<br />(a) ��.({
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />i
<br />i
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />i
<br />o
<br />OTHgR OG�g(CC(NT IONS FConditions contributing to the death but nd relaled PART
<br />PART PREGNANCY
<br />III IF FEMALE, WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24. AUTOPSY
<br />k
<br />25 WAS CASE REFERRED TO MEDICAL
<br />- YEXAMINEFI OR CORONER?
<br />�-., -h J s
<br />II
<br />' (Ages
<br />10 -541 Yes No
<br />Yes El No
<br />yes No rW
<br />26a.
<br />26b, DATE1OF INJ11RY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Uneetermmad
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f ott- a �QaiJ81RY -Sft. farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />tl pecifyi
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />A.
<br />C
<br />S z
<br />- J~ O�
<br />27b. DATE (W... Day. YrJ
<br />`✓'
<br />28c. PRONOUNCED DEAD /Mo. Day. Yc/
<br />T '
<br />n �-
<br />o
<br />6 k y
<br />�So
<br />M
<br />M
<br />3
<br />° o, °
<br />CD
<br />28e. On the basis of examination and or investigation, in my opinion death occurred of
<br />' �_.cause(sl stated.
<br />u
<br />the time, date and place and due to the cause(s) stated.
<br />,
<br />(Sign and Ti
<br />(S. nature and Tide
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />.a HAS ORGAN OR TISSUE DONATION BEEN C IDERED?
<br />30.b WAS CONSENT GRANTED?
<br />g
<br />-j' ❑ YES NO
<br />r A
<br />CD
<br />7
<br />N
<br />. ,
<br />-�
<br />z
<br />c-n
<br />co
<br />cn
<br />N
<br />O
<br />WHEN INS COPYCARRAES TIE RAISED SEAL OF THE NEBRASKA HEALTH ANA _ ES
<br />SYSTEM, IT CERTIFES TtE BELOW TO BE A TRUE COPY OF THE ORIGINAL � �.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISi�$ 1 - em
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE /� (� V h-�-
<br />MAR 6 20U3 v V V N L
<br />ASS/ST�{IfF- -S'i�: '- �_ � TAR;;-
<br />LINCOLN, NEBRASKA HEALTH ANDHUIN�kLIC SY�fA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICB- 0T 14' A-AM- i1PPORT
<br />VITAL STATISTICS = 0 3 02425
<br />C'F F. .RTTFTrAT OF DRATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Mont. Day Year)
<br />Ardith LeIla Kokes
<br />Female
<br />March 3, 2003
<br />4. CITY AND STATE OF BIRTH
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH /Monts. Day. Year)
<br />MOS I DAYS
<br />5c. HOURS' MINS
<br />Hampton, Nebraska
<br />(Yrs.) 75 5b,
<br />January 31, 1928
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -30 -2329
<br />HOSPITAL: © Inpatient OTHER ❑ Nursing Home
<br />ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /Moot institution, give street and number/
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specdy,
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I Yes [j No ❑
<br />Hall
<br />8a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Inctudng zip code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />3210 E. Gregor •68801
<br />Yes UNo ❑
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY fe.g_ Italian. Mexican, German, etcl
<br />12. a MARRIED ❑ WIDOWED
<br />'3 NAME OF SPOUSE (if wde give maiden name)
<br />etc.) (Specify)
<br />White
<br />Pat;
<br />ISPat; 1
<br />NEVER DIVORCED
<br />Edwin Kokes
<br />M R,
<br />CUPATK)N (Give kindot work dare dung most 14b.
<br />KIND OF BU SINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10- t 21 Cdlege 11 -4 or 5.I
<br />Me, even it etrredl
<br />tician
<br />Cosmetolo
<br />1 Year
<br />AME FIRST MIDDLE LAST 1 7
<br />FWASDECEASED
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />rman Troester
<br />Helen Salchow
<br />ASED EVER IN US. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />nk.) (If yes, give war and dates of services(
<br />No I --- - - - - --
<br />Edwin Kokes
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />3210 E. Gregory, Grand Island, Nebraska 68801
<br />20. LMER - SIGNATURE 8 LICENSE NO.
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY - NAME
<br />Q-•� �/I 44
<br />© Burial ❑ Removal
<br />Mar. 7, 2003
<br />Sunset Memorial Gardens
<br />22a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Crematim ❑Donalich
<br />Hastin gs, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Is). III). AND (q) Interval between onset and death
<br />✓pART �
<br />I • {� I� WSJ
<br />(a) ��.({
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />i
<br />i
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />i
<br />i
<br />(c)
<br />OTHgR OG�g(CC(NT IONS FConditions contributing to the death but nd relaled PART
<br />PART PREGNANCY
<br />III IF FEMALE, WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24. AUTOPSY
<br />k
<br />25 WAS CASE REFERRED TO MEDICAL
<br />- YEXAMINEFI OR CORONER?
<br />�-., -h J s
<br />II
<br />' (Ages
<br />10 -541 Yes No
<br />Yes El No
<br />yes No rW
<br />26a.
<br />26b, DATE1OF INJ11RY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Uneetermmad
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f ott- a �QaiJ81RY -Sft. farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />tl pecifyi
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />S z
<br />- J~ O�
<br />27b. DATE (W... Day. YrJ
<br />27c. TIME OFFDEATH
<br />28c. PRONOUNCED DEAD /Mo. Day. Yc/
<br />28d. PRONOUNCED DEAD (Hourl
<br />6 k y
<br />�So
<br />M
<br />M
<br />3
<br />° o, °
<br />27d. To the best of my knowledge. deal curred time ate and place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred of
<br />' �_.cause(sl stated.
<br />u
<br />the time, date and place and due to the cause(s) stated.
<br />,
<br />(Sign and Ti
<br />(S. nature and Tide
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />.a HAS ORGAN OR TISSUE DONATION BEEN C IDERED?
<br />30.b WAS CONSENT GRANTED?
<br />X ❑ YES �"AO ❑ UNKNOWN
<br />-j' ❑ YES NO
<br />❑ YES NO
<br />"9 •1 "I
<br />
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