Laserfiche WebLink
STATE OF NEBRASKA <br />Iia .6MemntMe6)9.I 'R)ibD➢xr roYget ettag 4)'l1S'P(@0BS?mv mrNenn t <br />WHEN TJ t3 COPYrCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT comp THE DOCUMENT BELOW TO <br />EE A TRUE COPT '£?I= T448;ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR vtrA't RECORDS <br />MAW 0 '7 X024 <br />LINCOLN. NEBRASKA <br />202401 7 SS STANT STATE REGISTRAR <br />SARAH BO HN ENKAMP <br />DEPARTMENT OF HEALTH <br />MSDtHUMAN SERVICES <br />N DEOEDEN:Y S NAI <br />STALE OF NEBRASKA— DEPARTMENT OF HEALTH AND HUMAN SERVICES'FINANCE AND SUPT <br />CERTIFICATE OF DEATH <br />,(FIrAI, Middle.. lett <br />.lanes . , Ann Jarecke <br />LATE OA TERRITORY. ORF©9EION COUNTRY OF BIRTH Si. AGE LaslHInhda <br />(Yn.l <br />Colurbus. Nebraska <br />SOCIweEcovirvN(are R <br />506-60-9778 <br />66 }AOILITY:MA <br />Cr <br />G'z'ap .Taland _ 68803: <br />Lc�pitTara <br />59 <br />2, SEE <br />Female <br />sx UNDER I DAY <br />1401. <br />DAYS <br />HOURS <br />MINS. <br />256 <br />3. DATE OF DEATH (Md.,Day,Yrt.y <br />May 6, 2007 <br />B. DATE OF BIRTH (Mo., Day, Yr,) <br />PUCE <br />HOSPITAL <br />NuIIdl1 piv1 11r/e1 and number) <br />rancid Skilled Care <br />ORTc)WN O DEATH Canada ZI Code). <br />Nebraska <br />2dI <br />•+1eapaaini cams <br />O ERIOWpat.M <br />ixs <br />August 8, 1947 <br />QNunbgHanvLTC OHnaplw?ICIM <br />O Decedeal Ham <br />O O nar(Specayl <br />ib:CO(MTY <br />Hall <br />yA: COUNTY OF DEATH <br />Hall <br />It. CITYORTOWN <br />Grand Island - <br />s3:APT; HO :: <br />V.21P CODE <br />61,8 out: Road <br />TIME QF OEATit ,,anted O nom Marded <br />j: <br />FI <br />5'. <br />O DI•oicad U Unhnewn., <br />rFl dl, Middle, <br />:'chard <br />IN. NAME OF $.:OUSE (0SsI )AIOMte. Last Si <br />gy <br />68801 <br />ag. INS EIE CITY LIMITS <br />2 YES O NQ <br />MI.. give 01.NNN mat <br />Frank <br />recke <br />R IN (1 S ARMED FORCES? One dales or sewn* B yet. <br />a unNL) .nt3 <br />ICOrus <br />14a. INFORMANT -HASTE <br />Frank Jarecke <br />11.:> Mlddle, <br />Ila <br />OFDISPOSITION /ea,EMBALMER.SIGNATURE <br />0D0M44 Nat Embalmed <br />OtimononmI <br />Ramose Ct OHI rISpa*Nyl:.... <br />'SHANE NO:: <br />St CEMETERY. CREMATORY OR OTHER LOCAtll <br />Malden 8enhlin1) <br />Burner <br />14b. RELATIONSHIP TO DECEI <br />Husband <br />II.. DATE (Mo., Day, YT ) <br />May 7. 2007 <br />GITYITOWN STATE <br />Westlawn Meorial Park C.rema.t.ory;. <br />2a P NERX t 14E N .MH*ND MAR(NDADDRESS (SkuA Clh er mTens SUN) <br />eet Grand; I = len <br />12 W 2n <br />Grand Island, Nebraska <br />17b.110 C <br />eb as <br />SE OF 0 ATH (See>tnalrui t ens end>.rsrnples) <br />68801 <br />imet ale thalnAtEaufis4ONlles, Alvan. a co mpAcaaorts-a.t di a ny (ALAN M1 Non 00 NOT enhr1/rfMa11rants such as mks meat <br />,1rr*ALiY MIADIMdtltlbtIENt n WNW showing BN Ni iagy. DO NOT ABBREVIATE. Env only anon auto analn/.Add Adeftwal Mel E mantas. <br />IMMEDIATE CAUSE: ?; e <br />e8 OUE TQ:q) AB A O0ISE011 <br />"L4346(4'. (+-eo s-4- ca, —„ * 4 G3 c..N gfc <br />*lip DUE <br />0.OR AS ACONSEQUENCE OF: <br />ie P. T N TITH R ISI K:ANT P.ONDITIONS-Condnlan canMetaing to the dfNh bel not HaLblig In dK urdt(Ging taaNa SI$S.Ira:•PART I. 1a. WAS MEDICAL EXAMINER <br />•OR CORONER CONTACTED? <br />003ttel# e vu 0 YES NO <br />• <br />2 <br />g IF FE14AT E Ns (AA ' t DEATH R11i 1f TpkN$N �iTAAON INJURY 711 WAS AN AUTOPSY PEAFORME <br />!ya>i!d at(a.A'A(Sant alae OHomkda tl pdrarf?paaplr �,r <br />nl (011146'OmA O AecrdanlO Minos bnntlgadbn <br />DPIlstert9(e ❑ YE8 }L NO <br />CI Pnealdan <br />OSunhat 0Could not wdaamlmN <br />Na PNeaeni, bui pregml)1 td»dpAS d0!YFM loam <br />C+) Ab110110lg!knf prtrFlAIR.43Nyalb I Taw biiQhe dadlh <br />i1 Uribrtd.A 11 d+ lrEWRSldALTM you <br />b. TIME:0FINJURY 22c. PLACE OF INJURY+AI hang, Ip <br />m <br />SA DATE. <br />May 6, ] <br />007 <br />21a, DATE STONED (Mo., Day, Yr.) <br />lab. TIME OF DEATH <br />Owl Kr/ <br />wi hires <br />NATIMEpF DEATH <br />o� <br />Am <br />icautNA.$1 ani Om dere and piaci <br />Calmanefinu) • <br />24e. PRONOUNCED DEAD tiAo., Dat Yr.) <br />Id: TIME PRONOUTATED DEAD <br />In <br />Zea. 00 11+1 bans al etaminNon and/01 brvadgaNn. Inmy .Priliso ectwredn , <br />He dme. Nu and Mace and due 1a lM counts) Wont (Sig INN and ?IBS) <br />S`... <br />IT,NAWE. DACDRESSOfCERTIFIER (PHYSICMN;CORONER'SPWYSICIANOR <br />KiSnher1v 111rka11a: M.11. 724 Nartjt CuA?ter. Ave <br />TTITEDEATH? 261. HAS ORGAN OR TISSUEOO14*ThON <br />D PSIDAS 61Y 0 UNKNOWN D YES L NO <br />MET) (hnie Fdnty <br />P Grand, Inland. Nebraska 08803 <br />Ant <br />ENT CONSIDERED? <' Nb. WAS CONSENT GRANTED? <br />NW Appacabie II Zea i. NO D Y <br />D NO <br />280. DATE FILED BY MA_ DISIRAI(M2 t.l <br />