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Index against: Lot Twenty -two (22) in West Lawn Addition to Grand Island,
<br />Hall County, Nebraska
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH S Sv
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_ SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AtNLEYI. COOPER
<br />12/17/2003 ASSISTANT STATT -V ?REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE.AND SUPPORT
<br />VITAL STATISTICS - 0 3 14206
<br />rP.R TTFTr A TF OF nP A TT4
<br />T - NAM E FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />�IDECFDE.l
<br />Peggy D'Marie Stoppkotte
<br />Female
<br />December 11, 2003
<br />Y AN STATE OF BIRTH 11(not 0 U.S.A.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER i YEAR
<br />'
<br />16. DATE OF BIRTH (Month. Day. Year)
<br />c
<br />Sc. HOURS' MIN$.
<br />Belgrade, Nebraska
<br />(Yrs.) 67 �51b.
<br />January 10, 1936
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: F Inpatient OTHER: ❑ Nursing Home
<br />507 -42 -4866
<br />❑ ER Outpatient ❑ Residence
<br />O i
<br />N 'l7
<br />❑ DOA ❑ Otherrspecdw
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yea ® No F1
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN 08 LOCATION
<br />9d. STREET AND NUMBER pncludtng Zip(
<br />SIDE CITY LIMITS
<br />Hu3otrAve68803
<br />Hu
<br />o �.,
<br />Yes ® No ❑
<br />Nebraska
<br />Hall
<br />Grand Island
<br />..
<br />1824 N
<br />10. RACE - (e.g.. White. Black, American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican. German, etc)
<br />12. n MARRIED ❑ WIDOW 1
<br />13, NAME OF SPOUSE /It wife, give maiden name)
<br />010 (Specify)
<br />White
<br />(Spec.yl
<br />I American
<br />[I NEVER DIVORCED
<br />M
<br />Robert Stoppkotte
<br />14a. USUAL OCCUPATION (Give kind of work done during most - 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Element ar or Secondary 10 -121 Colle a If .4 or 5-1
<br />�L
<br />CD
<br />Housewife
<br />Domestic
<br />1�
<br />16. FATHER -NAME FIRST MIDDLE LAST 1
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Verne Russell
<br />Etta Stricklin
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />)Yes . no. or unk.l (it yes. give war and dates of services)
<br />No
<br />Robert Stoppkotte
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />Il.
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />El Burial El Removal
<br />Dec. 11 2003
<br />Central NE Cremation Servi(
<br />( -T
<br />O
<br />Apfel- Butler - Geddes
<br />®Cremation ❑Donation
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET 08 R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND fell I Interval between onset and death
<br />PART lal L�!
<br />��7 1 � VV� ` t� f1
<br />it
<br />r1 I
<br />C L'!Eto' i
<br />(bl c i !viTt�ST'i ,i� S
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between Onset and deem
<br />CD
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PREGNANCY
<br />III IF. FEMALE. WAS THERE A 2a
<br />IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />II
<br />/Ages
<br />10 -54). Yes No �
<br />Yes No
<br />UT
<br />i
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />U�
<br />GO
<br />FJAccident n
<br />Undetermined
<br />M
<br />Suicide � Pending
<br />CID
<br />;X
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />200400667
<br />Deice
<br />27a. DATE OF DEATH /Mo. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />�
<br />12/11/03
<br />> <'
<br />M
<br />y�
<br /><
<br />27b. DATE SIGNED (Mo.. Day Yc/
<br />27c. TIME OF DEATH
<br />2Bc. PRONOUNCED DEAD tMa. Day. Yr)
<br />28d. PRONOUNCED DEAD (HOUrI
<br />r
<br />o
<br />5:12 a.m.
<br />J
<br />�'�
<br />M
<br />wz�
<br />M
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />,° �
<br />z
<br />causelsl stated. _
<br />1i
<br />8
<br />the time, date and place and due to the causefs) stated.
<br />(Signature and 7itlel ✓'�- V vt i�
<br />1 ►
<br />ISi nature and Title/ ►
<br />J
<br />29. DID TOBAGGO USE CONTRIBUTE TO THE
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />0
<br />Index against: Lot Twenty -two (22) in West Lawn Addition to Grand Island,
<br />Hall County, Nebraska
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH S Sv
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_ SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AtNLEYI. COOPER
<br />12/17/2003 ASSISTANT STATT -V ?REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE.AND SUPPORT
<br />VITAL STATISTICS - 0 3 14206
<br />rP.R TTFTr A TF OF nP A TT4
<br />T - NAM E FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />�IDECFDE.l
<br />Peggy D'Marie Stoppkotte
<br />Female
<br />December 11, 2003
<br />Y AN STATE OF BIRTH 11(not 0 U.S.A.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER i YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH (Month. Day. Year)
<br />MOS. I DAYS
<br />Sc. HOURS' MIN$.
<br />Belgrade, Nebraska
<br />(Yrs.) 67 �51b.
<br />January 10, 1936
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: F Inpatient OTHER: ❑ Nursing Home
<br />507 -42 -4866
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name (It not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Otherrspecdw
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yea ® No F1
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN 08 LOCATION
<br />9d. STREET AND NUMBER pncludtng Zip(
<br />SIDE CITY LIMITS
<br />Hu3otrAve68803
<br />Hu
<br />o �.,
<br />Yes ® No ❑
<br />Nebraska
<br />Hall
<br />Grand Island
<br />..
<br />1824 N
<br />10. RACE - (e.g.. White. Black, American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican. German, etc)
<br />12. n MARRIED ❑ WIDOW 1
<br />13, NAME OF SPOUSE /It wife, give maiden name)
<br />010 (Specify)
<br />White
<br />(Spec.yl
<br />I American
<br />[I NEVER DIVORCED
<br />M
<br />Robert Stoppkotte
<br />14a. USUAL OCCUPATION (Give kind of work done during most - 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Element ar or Secondary 10 -121 Colle a If .4 or 5-1
<br />�L
<br />of working file, even itretired)
<br />Housewife
<br />Domestic
<br />1�
<br />16. FATHER -NAME FIRST MIDDLE LAST 1
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Verne Russell
<br />Etta Stricklin
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />)Yes . no. or unk.l (it yes. give war and dates of services)
<br />No
<br />Robert Stoppkotte
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1824 North Huston Ave Grand Island, Nebraska 68803
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />El Burial El Removal
<br />Dec. 11 2003
<br />Central NE Cremation Servi(
<br />22a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />®Cremation ❑Donation
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET 08 R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND fell I Interval between onset and death
<br />PART lal L�!
<br />��7 1 � VV� ` t� f1
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and deatn
<br />r1 I
<br />C L'!Eto' i
<br />(bl c i !viTt�ST'i ,i� S
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between Onset and deem
<br />Iq �� b ' � j �K- �- t �L i 2 ti! CV � r
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PREGNANCY
<br />III IF. FEMALE. WAS THERE A 2a
<br />IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />II
<br />/Ages
<br />10 -54). Yes No �
<br />Yes No
<br />Yes No RT
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />FJAccident n
<br />Undetermined
<br />M
<br />Suicide � Pending
<br />26e. INJURY AT WORK
<br />261. p
<br />boildirllN�.JURY %S yr. farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />Deice
<br />27a. DATE OF DEATH /Mo. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b TIME OF DEATH
<br />12/11/03
<br />> <'
<br />M
<br />y�
<br /><
<br />27b. DATE SIGNED (Mo.. Day Yc/
<br />27c. TIME OF DEATH
<br />2Bc. PRONOUNCED DEAD tMa. Day. Yr)
<br />28d. PRONOUNCED DEAD (HOUrI
<br />r
<br />(� �,
<br />5:12 a.m.
<br />J
<br />�'�
<br />M
<br />wz�
<br />M
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />,° �
<br />2 � �
<br />causelsl stated. _
<br />1i
<br />8
<br />the time, date and place and due to the causefs) stated.
<br />(Signature and 7itlel ✓'�- V vt i�
<br />1 ►
<br />ISi nature and Title/ ►
<br />J
<br />29. DID TOBAGGO USE CONTRIBUTE TO THE
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />`DEATH?
<br />❑ YES ❑ NO VY UNKNOWN
<br />❑ YES �NO
<br />❑ YES ��NO
<br />�♦
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) IType or iRforl
<br />Dr. Peter Ledakis M.D. 2116 West Faidle Ave Grand Island, Nebraska 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />e
<br />
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