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<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICESI
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO�tD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIs /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />ANLEY S COOPER
<br />1/6/2004 200400463 ASSI TAN" TMEGIS7*010
<br />LINCOLN, NEBRASKA HEALTH ANO:1 UMAN Mlf
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICPS FINANCE AND SUPPORT
<br />VITAL STATISTICS +� A
<br />C:RRTTFTrATR nV nVA rU 1 4
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Martha
<br />Doris Daily
<br />Female
<br />December 3, 2003
<br />4. CITY AND STATE OF BIRTH Minot in U.S.A.. name country)
<br />Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day Year)
<br />rn
<br />(Yrs.) 74 Sb. MOS. DAYS 5c. HOURS' MINB. May 14, 1929
<br />7. SOCIAL SECURTIY NUMBER
<br />M
<br />• 508 -30 -7728
<br />HOSPITAL: Inpatient OTHER' Nursing Home
<br />- -- ❑
<br />8b. FACILITY -Name /p not msti upon, give street and number) ❑ ER Outpatient Residence
<br />Home: 4044 Buckingham Drive ❑ DOA ❑ Other (Spe,dvl
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />o �
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<br />Be. COUNTY OF DEATH
<br />Grand Island
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<br />9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island 4044 Buckingham Dr. Yes ® No ❑
<br />C:: 7--
<br />N
<br />�.
<br />CD
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />o/ working /Ae, even i/renied)
<br />Z
<br />15. EDUCATION )Specify only highest grade completed)
<br />Elementary or Secondary 21 College 11 -4 or 5 -I
<br />11
<br />Dental Assistant
<br />12:30 A
<br />M
<br />Dental Office
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />"t
<br />John
<br />Meinecke
<br />Martha Koch
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />w 12 -3- 2003 9C 2.05 A
<br />19a. INFORMANT -NAME
<br />(Yes, no, or unk.)
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<br />c!'
<br />Gerald D. Daily
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<br /><-
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION . 21 b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />°
<br />13 Burial ❑Removal Dec. 6, 2003 Westlawn Memorial Park
<br />22a. FUNERAL HOM - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑Cremation E] Donation
<br />❑
<br />Grand Island, NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY
<br />OR TOWN. STATE, ZIP)
<br />r,
<br />Island, NE. 68801
<br />23. r IMMFDIATF (,AI ICF
<br />cuTCO n... .. ...,�...
<br />32b. DATE FILED BY REGISTRAR (Mo., Day Yr.)
<br />�,
<br />aEC 1 S 2003
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<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICESI
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO�tD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIs /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />ANLEY S COOPER
<br />1/6/2004 200400463 ASSI TAN" TMEGIS7*010
<br />LINCOLN, NEBRASKA HEALTH ANO:1 UMAN Mlf
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICPS FINANCE AND SUPPORT
<br />VITAL STATISTICS +� A
<br />C:RRTTFTrATR nV nVA rU 1 4
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Martha
<br />Doris Daily
<br />Female
<br />December 3, 2003
<br />4. CITY AND STATE OF BIRTH Minot in U.S.A.. name country)
<br />Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day Year)
<br />Grand Island, Nebraska
<br />(Yrs.) 74 Sb. MOS. DAYS 5c. HOURS' MINB. May 14, 1929
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />• 508 -30 -7728
<br />HOSPITAL: Inpatient OTHER' Nursing Home
<br />- -- ❑
<br />8b. FACILITY -Name /p not msti upon, give street and number) ❑ ER Outpatient Residence
<br />Home: 4044 Buckingham Drive ❑ DOA ❑ Other (Spe,dvl
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yea ® No ❑
<br />Hall
<br />9a. RESIDENCE - STATE 9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island 4044 Buckingham Dr. Yes ® No ❑
<br />10. RACE - (eg., White. Black. American Indian. 11. ANCESTRY le.g.. Italian, Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE Ill wife. give maiden name)
<br />etc.) ISPeciNl (specify)
<br />White
<br />NEVER
<br />American DIVORCED Gerald D. Daily
<br />MARRIED
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />o/ working /Ae, even i/renied)
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION )Specify only highest grade completed)
<br />Elementary or Secondary 21 College 11 -4 or 5 -I
<br />11
<br />Dental Assistant
<br />12:30 A
<br />M
<br />Dental Office
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />John
<br />Meinecke
<br />Martha Koch
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />w 12 -3- 2003 9C 2.05 A
<br />19a. INFORMANT -NAME
<br />(Yes, no, or unk.)
<br />fit yes. give war and dates of services)
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<br />No
<br />28e. On the basis of examination and,or investigation, in my opinion death occ rred at
<br />Gerald D. Daily
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />4044.Buckingham Drive,
<br />Grand Island, NE. 68803
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION . 21 b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />S, and Titlel ►
<br />13 Burial ❑Removal Dec. 6, 2003 Westlawn Memorial Park
<br />22a. FUNERAL HOM - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑Cremation E] Donation
<br />❑
<br />Grand Island, NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY
<br />OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand
<br />Island, NE. 68801
<br />23. r IMMFDIATF (,AI ICF
<br />cuTCO n... .. ...,�...
<br />- -- - - - - mrervai oerween onset anti death
<br />PI ) NATURAL CAUSES
<br />UNKNOWN
<br />DUE 70, OR AS A CONSEQUENCE OF Interval between onset and seam
<br />r (b)
<br />DUE TO. OR AS A CONSEQUENCE OF. Interval between onset and dean
<br />I
<br />Icl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />WAS CASE REFERRED TO MEDICAL
<br />II PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />)Ages 10 -54) Yes No
<br />Yes No
<br />Ves No
<br />26
<br />2 V DATE OF INJURY (Mo.. Day. Yr.)
<br />?� HOUR OF INJURY
<br />2fid DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />�-
<br />Suicide Pending
<br />aye INJURY AT WORK
<br />25}r PLACE OF. INJURY - At hoe, farm. street. factory
<br />�/ office building. etc. /Speer
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />❑J�.
<br />Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />x„
<br />27a, DATE OF DEATH (MO.. Day. Yr.)
<br />�8. DATE SIGNED /MO.. Day Vr.) 2By TIME OF DEATH
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<br />12:30 A
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<br />27b. DATE SIGNED /Mo.. Day Vcl
<br />27c. TIME OF DEATH
<br />28g. PRONOUNCED DEAD /MO.. Day Yr.) 28d7 PRONOUNCED DEAD /HOUrr
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<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />causelsl stated.
<br />28e. On the basis of examination and,or investigation, in my opinion death occ rred at
<br />the
<br />the time. date and platTend cau els) stated.
<br />19gnature and Mfie) ►
<br />S, and Titlel ►
<br />2 DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b AS CON G ANTED
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑
<br />YES NO
<br />31.�NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print)
<br />J4 SGT. E.G. EDWARDS
<br />131 S LOCUST ST, GRAND ISLAND, 'NE 68801
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo., Day Yr.)
<br />�,
<br />aEC 1 S 2003
<br />
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