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WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND_HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGHICOION FILE mom THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S S`_SEC1pttI H,C /S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE • NOV 14 2001 LINCOLN, NEBRASKA d �`, 2 2 4 0 4 0 0 4 '" ANLEY S-00oPER ir_,Ss/srr�uar STATE REGISTRAR HEALTFFAIJAN SERVI M ,• STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND _ VITAL STATIST[CS - CERTIFICATE OF DE' 1 12558 1. DECEDENT - NAME FIRST MIDDLE LAST Richard Lewis Whitaker 2 SEX Male t3. DATE OF DEATH (Month. Day. Year) November 7, 2001 4. CITY AND STATE OF BIRTH (M not it USA.. name country) Hastinnnnnnns, Nebraska 5a. AGE - Last Birthday Yrsl 67 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) May 24, 1934 5b. MOS DAYS Sc.HOURS i MINS 7. SOCIAL SECURTIY NUMBER 507-36-3423 8a PLACE OF DEATH HOSPITAL. ❑ inpatient OTHER ❑ Nursing Home ❑ ER Outpatient i-' Residence ❑ DOA ❑ Other (Specify, 86 FACILITY - Name /lino! institution, give sheet and number) 106 N. 5th >L 8c. CITY. TOWN OR LOCATION OF DEATH • Doniphan 8d. INSIDE Yes CITY LIMITS al • No ❑ Be. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE I Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Doniphan 9d. STREET AND NUMBER (Including Zip Code) 106 N. 5th 68832 9e INSIDE CITY UMITS Yes ® No ■ 10. RACE - le.g., White. Black. American Indian. etc)ISoecOy) White 11. ANCESTRY le.g. . Italian. Mexican. German, etc) (Specify)NEVERMARRIED American 12. ri ❑ MARRIED ❑ WIDOWED DIVORCED 13. NAME OF SPOUSE (11 wile. give ma den name) Susan Hendrickson 14a. USUAL OCCUPATION (Give kind of work done during most of working life. even i1 retired) Maintenance 14b. KIND OF BUSINESS INDUSTRY Steel Building Manufacturing 15. EDUCATION (Speaty only highest grade completed) Elementary or Secondary (0.121 College 11 -4 or 5.1 I 1 Year (6. FATHER - NAME FIRST MIDDLE LAST Lewis C. Whitaker 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Bernadine A. Vansant 118. WAS DECEASED - (Yes. no: or unk.) i No, EVER IN U.S. ARMED FORCES? (11 yesgive war and dares of services' 19a INFORMANT - NAME Susan Whitaker f96. INFORMANT MAILING ADDRESS (STREET OR RF D N9rCITY OR TOWN. STATE. ZIP) 106 N. 5th, Doniphan, Nebraska 68832 20. EMR>< SIGNATU6Q a UCEWGE NO. 22a. FUNERAL HOME/ GAME Livingston -Sondermann F.H. 21a METHOD OF DISPOSITION Bunal ❑ Removal ❑ Cremation ❑ Donauon 216. DATE 21c. CEMETERY OR CREMATORY NAME Nov. 10, 2001 Cedarview Cemetery 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Doniphan, Nebraska 226. FUNERAL HOME ADDRESS (STREET OR RF.D. NO.. CITY OR TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803-4050 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ia). Ib). AND (c)) TEsy PART y , DUE TO, OR AS A CONSEOUENCE OF (b) /� 4-7 r/ DU TO. OR AS A CONSEOUENCE OF: (c) Interval between onset and death ,fes .� Interval between onset and death / Interval between onset and death OTHER SIGNIFICANT CONDITIONS - CaMrtions contributing to the death but not related PART 11 PART 81 IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10-54) Yes n No n 24. AUTOPSY K Yes n No Al 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? , >z Yes n No 26a. • Accident IIII Undetermined 0 Suicide Li Pending Homicide Investigation n❑ 266. DATE OF INJURY (Mo. Day. Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED - 26e. INJURY AT WORK Yes No ❑ 261 P4ACE QF INJURY - At home, farm. street factory oiEce 6511011,1, etc. fSpec%Y, 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE -g tl F 27a. DATE OF DEATH (Mo.. Day Yr) �( November 7,2001 >L 28a. DATE SIGNED /Mo.. Day. Yr.) 280. TIME OF DEATH M =-a 28c. PRONOUNCED DEAD (Ma. Day. Yr/ 28d. PRONOUNCED DEAD (Hood 7b. DATE SIGNED (Mo.. Day. Yr) November9, 2001 2D. TIME OF DEATH C 1: 30pm M M ct 28e. On the basis of examination and/or investigation. in my opinon death occurred at the time. date and place and due to the cause(, stated. ' (Signature and Title) ► - 7d. To the best o( my knowledge. death occurred at me 5' :, date and dace anddue to the vcausels) stated. - ''Signature and Title) %rte :% 210 DID TOBACCO USE CONTRIB TO THE DEATH? ( • ❑ YES f< NO ❑ UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 (- ❑ VES NO 30.5 WAS CONSENT GRANTED? j / ❑ VES p0 NO NAME AND ADDRE�CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) JTyge OyPriml Dr Jane A McDo ald M 32a. REGISTRAR • 00 Alpha Grand Island,NE 68803 320. DATE FILED 8Y REGISTRAR (Ma. Day Yr) NOV 13 2001