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MEN TENS COPY CABS ThE RAISED SEAL OF THE NEBRASKA MEUTlf�
<br />SYSTEM IT CERTMES THE BELOW TO BE A TRUE COPY OF THE ORIG _ _ - AE IYITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATES SECT( A►HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _
<br />3: C4>ORER
<br />12/12/2003 AswAw -srAJj s_RAR
<br />LINCOLN, NEBRASKA 2 0 0 4 0 0 3 5 6HEALTH AND SYSTEM
<br />=- -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVXTSfJNANCE AND SUPPORT
<br />VITAL STATISTICS 3 13952
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IMonth. Day. Yearl
<br />Betty Ann Hopkins
<br />Female
<br />December 8, 2003
<br />n
<br />5a. AGE -Las( Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 OAY
<br />6. DATE OF BIRTH /Mw1tl1. Day. Year/
<br />Dannebrog, Nebraska
<br />(Yrs.)
<br />70
<br />5b. MOS. I DAYS
<br />T
<br />1 December 14, 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />M D CA
<br />507 -34 -6742
<br />HOSPITAL. ® Inp - OTHER ❑ Nursing Home
<br />---- ❑ . ER Outpatient ❑ Residence
<br />C> ___4
<br />T� CD
<br />n
<br />Bd. INSIDE CRY LIMITS
<br />C=
<br />o
<br />Grand Island
<br />Yes E] No ❑
<br />Hall
<br />9a. RESIDENCE - STATE 9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Codel 9e. INSIDE CITY LIMITS
<br />ebras a __ __j Hall Grand Island Yes&J No
<br />-4 17111
<br />etc.) (Specify) (Specify) American ❑NEVER DIVORCED
<br />Delmer Hopkins Dec)
<br />I
<br />White
<br />Wh MARRIED-
<br />14a. USUAL OCCUPATION LGive k/ndof work done dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elem ntary or Secondary (0 -12) College 11 -4 or 5�i
<br />Grade
<br />of working life, even if retired/
<br />Cook
<br />Restaurant
<br />9t1
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />M
<br />D
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.l ht yes. give war and dales of services)
<br />Barbara Berggren
<br />No ----- - - - - --
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIP)
<br />310 W. 12th, Wood River, Nebraska 68883
<br />20.E ME E 8 LIC EN O:
<br />�❑X
<br />21 a. METHOD OF DISPOSITION
<br />M
<br />n
<br />y
<br />Burial ❑Removal
<br />Dec. 12, 2003
<br />Westlawn Memorial Park
<br />22a NERAE
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin st6n- Sondermann. F.H
<br />ir
<br />❑0Ba°°" 11 Dona10
<br />Grand Island, .Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />._..___ _ -.... _..- _..._� ..- .....,� �....._. ,.. ..,.. ,_„ I - _.Interval heWreen msat and seam
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<br />Lots Seven (7)
<br />and Eight
<br />(8),
<br />Block Thirty -Six
<br />(36),
<br />Lambert's
<br />Addition
<br />to the City of
<br />Grand Island,
<br />Hall County, Ne.
<br />MEN TENS COPY CABS ThE RAISED SEAL OF THE NEBRASKA MEUTlf�
<br />SYSTEM IT CERTMES THE BELOW TO BE A TRUE COPY OF THE ORIG _ _ - AE IYITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATES SECT( A►HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _
<br />3: C4>ORER
<br />12/12/2003 AswAw -srAJj s_RAR
<br />LINCOLN, NEBRASKA 2 0 0 4 0 0 3 5 6HEALTH AND SYSTEM
<br />=- -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVXTSfJNANCE AND SUPPORT
<br />VITAL STATISTICS 3 13952
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IMonth. Day. Yearl
<br />Betty Ann Hopkins
<br />Female
<br />December 8, 2003
<br />4. CITY AND STATE OF BIRTH lNnot in U.S.A., name counhy)
<br />5a. AGE -Las( Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 OAY
<br />6. DATE OF BIRTH /Mw1tl1. Day. Year/
<br />Dannebrog, Nebraska
<br />(Yrs.)
<br />70
<br />5b. MOS. I DAYS
<br />5c. HOURS' - MINS.
<br />1 December 14, 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -34 -6742
<br />HOSPITAL. ® Inp - OTHER ❑ Nursing Home
<br />---- ❑ . ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /d not insaerdon, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other lSpecdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CRY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes E] No ❑
<br />Hall
<br />9a. RESIDENCE - STATE 9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Codel 9e. INSIDE CITY LIMITS
<br />ebras a __ __j Hall Grand Island Yes&J No
<br />10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican, German, etcl t2 ❑ MARRIED r�} WIDOWED 13 NAME OF SPOUSE fit wile. ,give maiden name)
<br />L1:
<br />etc.) (Specify) (Specify) American ❑NEVER DIVORCED
<br />Delmer Hopkins Dec)
<br />I
<br />White
<br />Wh MARRIED-
<br />14a. USUAL OCCUPATION LGive k/ndof work done dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elem ntary or Secondary (0 -12) College 11 -4 or 5�i
<br />Grade
<br />of working life, even if retired/
<br />Cook
<br />Restaurant
<br />9t1
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Robert Reimers
<br />Evel DeVore
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.l ht yes. give war and dales of services)
<br />Barbara Berggren
<br />No ----- - - - - --
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIP)
<br />310 W. 12th, Wood River, Nebraska 68883
<br />20.E ME E 8 LIC EN O:
<br />�❑X
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />4SIGNAT
<br />Burial ❑Removal
<br />Dec. 12, 2003
<br />Westlawn Memorial Park
<br />22a NERAE
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin st6n- Sondermann. F.H
<br />ir
<br />❑0Ba°°" 11 Dona10
<br />Grand Island, .Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />._..___ _ -.... _..- _..._� ..- .....,� �....._. ,.. ..,.. ,_„ I - _.Interval heWreen msat and seam
<br />- . -. -.. _..4 _..___
<br />/)
<br />%,PART
<br />=iaive c vr•a_VwVV v - - -- '--
<br />S A CONSEQUENCE OF Interval between onset and death
<br />I
<br />DUE 70, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but rat related PART III IF FEMALE. WAS THERE A 2a AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER?
<br />PART ,Y
<br />1
<br />(Ages 1Q - %) Yes No Yes No Yes No
<br />26a. -
<br />26b. DATE OF INJURY (Ma. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F Undetermined'
<br />M
<br />Suicide F1 Pending
<br />26e. INJURY AT WORK
<br />281. PLACE �i� �Y (St jf) , farm, street factory
<br />odlf6iccee
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />' Mo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr) 28b. TIME OF DEATH
<br />27a. DATE OF DEATH (
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<br />Sg
<br />�f 27b. DATE SIGNED (MO.. Day. Yr) 27c. TIME OF DEATH > 28c. PRONOUNCED DEAD /MO.. Day, Yr) 28d. PRONOUNCED DEAD (Hour;
<br />a < }
<br />X l OZ --� - 03 X Cj • /S f} w M
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<br />$z�
<br />8
<br />27d. To the best of my knowledge. des occurred at the 8me. ate and piece and due to the ° cg- 28e. On the basis of examinaaon and or investigation, in my opinion death occurred at
<br />�causelsl salted. c /�cil ~ c4 b the time, date and place and due to the causels) stated.
<br />i�J
<br />r (mss
<br />(Signature and Titel 11, (Signature and Tide 01
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />YES ❑ NO UNKNOWN E] YES NO 4* YES NO
<br />Ir
<br />31. N AND Dq� RESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( hype or Pnn
<br />#�(OO ��a.n� r ��C
<br />i J GtrcL �tc� � rn.b. ZttCo W. t t�lE
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.]
<br />DEC 11 200
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