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<br /> Lot 177 , Buenavista Subdivision, City of Grand Island, Hall
<br /> County, Nebraska.
<br /> WHEN TF�S COPY CARRIE3 THE RA/SED SEAL OF THE NE 3 -�jNqN y�/tV/CES
<br /> SYSTEII�?CERT�S THE BELOW TO BE A TRUE COPY OF THE���N F/LE W/TH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEIf�VIT� _ �y�yy�.J���g
<br /> THE LEOAL DEPOS/TORY FOR VITAL RECORDS _ ---"'--- -_- __
<br /> DATE OF/SSUANCE '- � - ��yy�p
<br /> _ ��;�'�"U Lt+
<br /> � 11 1999 _ __' - - ,---�ooPeR
<br /> ` � -�1.�*.4/3T > __I$liISTRAR
<br /> UNCOLN,NEBRASKA HE,q A� -,�s�M Rr
<br /> STATE OF NEBRASKA_pEpARTl1�NT OF HF.ALTH pl�
<br /> VifAL STA -- - - --=-_
<br /> CERTIFICATE � -
<br /> t.DECEDENT•NAME FIRST MIDDIE LAST � � �2. % � � 3.DA7E OF DEATH /Mprrm Day Vear/
<br /> Vera Alta Struble� Female.� Januar 29 1999
<br /> 4.CRV AND STATE OF 81RTH /Mnof n U.SA..neme cpmlry� 5a.AGE-Lui BiMday UNDER 1 VEAR �yNpER�DAY 6.DATE OF BiRTH /Alonah.Day.Year/
<br /> BOQ�u$�Nebraska ���I oC Sb.MOS I DAYS $c.HOURS' MINS.
<br /> • 7.SOCIAL SECURTtV NUMBER �� Au ust 31 1913
<br /> Ba.PLACE OF DEATH .
<br /> � 508-58-6473 HOSPITAL: � Inpatient OTHER: � NurSing Mome
<br /> 8b.FACILITV-Name /Mnd�nslilufipn,prv9 sheef aMnumDer/ -���- � ER Outpeuent � qesitlence
<br /> , Tiffany Square Care Center ❑ ooA � a,�„�,ty,
<br /> &.CITV.TOWN pR�OCATION OF DEATH 8E.INSIDE CITY LIMITS 8e.COUNTV OF DEATH
<br /> Grand Isiand ,,,, �f No � Ha��
<br /> 9a.RESIDENCE-STA7E , 9b.COUNTY 9e.CITV.TOWN OR LOCAT�ON 9d.STREE7 AND NUMBER (mc�uding Zp Code/ 9e INSIDE GTV LIMITS
<br /> Nebraska Hall Grand Island 423 E.Nebraska Ave.,68801 �e:�.] No❑
<br /> t0.RACE-(e.g.,W�Ne.BWCk.American Indian. 11.ANCES7RV Is.g..IWim.MeKican,perman,stcl � t 2.❑MARPoED �WIDOWED t3.NAME OF SPOUSE !N wAe.glve ma�rlen name/
<br /> �t,h7 I,}pa ciry� (SpetAyl
<br /> '• `e American NEVER DIVORCED
<br /> taa.USUAL OCCUPATION /G�ve kindd wak don�dwirg mosi J y! tID.KIND OF BUSINESS INDUS7RY n�' 15.EDUCATION �Spec�ry oniy n�ghast yn0e compleoea)
<br /> d Korkinq li/g.even il rMiedl ! •,�
<br /> Home Maker e�me��ry«s��,aa,��o.,2i ca��a�,-<a5•�
<br /> Domestic 11
<br /> 16.FATHER-NAME FIqST MIODLE UST � i7.MOTMEH FIRST MIDDIE MAIDENSURNAME
<br /> Charles Martin Tocke Martha M. Dethlefs
<br /> 18.WAS DECEASED EVER IN U.S.ARMED FORCES? 1ga.INFORMANT-NAME -
<br /> I�es.no.or unk.� Iil yes.grve war antl Cates d servicaa�
<br /> NO
<br /> 19b.INFORMANT MAIIING ADDRESS ISTREET Oq R,F.D.NO..CITV OR TOWN.STATE.ZiP�
<br /> 3321 Andrew Ave.,Grand Island, Nebraska 68801
<br /> 20.E LMEH-SIGNA`U 8 ENSE N 21 a.METHOOOF DISPOSITiON 21b.DATE 21 c CEMETERV OR CREMATOav�NAME
<br /> � #1071 �e���.� �Ae,,,o�,� 02/O1/1999 Westlawn Memorial Park Cemeter
<br /> 22 UNEfiAL HOME NAME 21tl.CEMETEfiY OR CREMATORV LOCATION Ci7v OF TOWN STATE
<br /> Apfel-Butler-Geddes Funeral Home ❑aem.„,� ❑o��a��o� Grand Island,Nebraska
<br /> 22b.FUNERAL HOME ADDRESS �STREET OH H.F.D.NO_CITV Qq TOWN.$TATE,ZIP� . -
<br /> 1123 West Second Grand Island, Nebraska,68801-5899
<br /> 23. IMMEDIATE CAUSE �ENTEfi ONLV ONE CAUSE PER UNE FOR lal.Ib�.AND�t�� i Inte�val betweqn onsei antl oeam
<br /> PART �C S!I/!G./I��4/ ��� � 1
<br /> lal i �/../�t�
<br /> W [
<br /> � DUE TO.OR AS A CONSEOUENCE OF� � Inlerval betwaen onse�antl tleam
<br /> �b� �J G �s ncJ L �f1.�1-tr ��-�r.�,�(/ ' � w,�,�
<br /> DUE TO,OR AS A CONSEOUENCE OF: ' irnerral pelwean onset ane tleam
<br /> �cl i
<br /> i
<br /> OTHER SIGNIFICANT CONOI7�ONS-CaWilions contribNrq M Me tleaM dA nq relate0 PART III IF FEMALE.WAS THERE A 2a AUTOPSY 25.WAS CASE REFERRED TO MEDICAL
<br /> PART PREGNANCV IN THE PAST 3 MONTMS� EXAMINER OF CORONEA'
<br /> II
<br /> �Ages 10-54� Ve5 No Ves No V85 No
<br /> �a� 26b DATE OF INJURV /MO_Day.Yc/ 26C.HOUR OF INJURV Z6A.OESCRIBE HOW INJUAV OCCURRED
<br /> � AccMen� � Untlele�mined
<br /> M
<br /> � Suicide � Penamg 26e.INJURY AT WORK 26f.PLACE QF.INJURV-qt�,larm.street.fadory 2fig.LOCATION STREET OR R.F.D.NO. C�TV OR TOWN - S7ATE
<br /> ❑ O O olf�ce arltlug.etc. /Specdy
<br /> Homiclde Invesugauon y� No
<br /> 27a.DATE OF DEATH /MO.Day vrJ 28a.DATE SIGNED /MO..Day.vr I 28b 7IME OP DEATH
<br /> ah s�� M
<br /> 27b.DATE SIGNED /MO.Day Ycl 27c TIME OF DEATH �k� 2BC.PRONOUNCED DEAD /MO.Day,YrJ 28tl,pqONOUNCED DEAD /HOUrI
<br /> ��� ��� -� l',o��J M ����
<br /> M
<br /> a 27tl.To�he best of my knowl a occurred et ,Eate antl a tlue to Ure ��� 2Be.On the basis ot examinauon arMror mvestigafion,in my oqnion deai�occurred at
<br /> ~c causelsl stated. ♦ /� � a the time,tlate aiW Dlace anA tlue Io the cau5els�slated.
<br /> (5 nalu�e and Title � � l Si neture antl Title�
<br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS OfiGAN OF 71SSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GFANTED?
<br /> � VES �__ � UNKNOWN � VES � NO � VES �NO
<br /> 3t.NAME AND ADDRESS OF CERTIFIER IPHVSICIAN,CqRONER'S PHYSICIAN OR COUNTY ATTORNEVI lTypo a Prinfl �
<br /> Dr. David R.Colan,729 N Custer,Grand Isl d,Nebraska 68803
<br /> 32a FEGISTRAq
<br /> 32b.DATE FILED BV REGISTRAR /MO.,Lyy yt/
<br /> .�,,,.,M FEB 101999
<br />
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