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O M P U) M U) Lot 2, Block 2 of Elm Place Addition to the City of Grand Island, Hall County, NE. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOAD-ON RL£ WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISIXS SUCTION; WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ DATE OF ISSUANCE N 200111835 NLEY& COOPER JUL 2 0 2001 ASSISTANT STATEREGISM" LINCOLN, NEBRASKA HEALTH AND-HUMAN SERVICES SYSTgI STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES PNANCE AND SIPPORT VTTAL STATISTICS _ 0 07044 CERTIFICATE OF DEATH -- 1 DECEDENT NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH /Month Day Yearl Hilda NMN Minor Female' June 19, 2001 a CITY AND STATE OF BIRTH Rf nohn U S.A. name country) (Ages 10 54I Yes No 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH lMonlh. Day Year) Yeovil, England [—I ACUdenl Undele"oed (Yrsl 86 September 29, 1914 Sb MOS DAYS 5d HOURS MINS 7 SOCIAL SECURTIY NUMBER Suicide [] Pendinq 26e INJURY AT WORK Be PLACE OF DEATH 26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 508 -10 -2087 i co 80 FACILITY -Name pl not institution, give street and number) Nrn ❑ DOA ❑ Other /Specify, 8c CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes ❑X No ❑ G Hall MC C p 0 9, INSIDE CITY LIMITS Nebraska Hall Grand Island 1411 W. Divison 68801 Yes X❑ No ❑ 10 RACE (a g, Wnite. Black American Ind-an 11. ANCESTRY leg .Italian. Mexican. German, etc) C01 W11 OWED t 3 NAME OF SPOUSE 111 wife qne maiden name) etc I (Soeclty) White (Speclfyl English NEVER DIVORCED James Minor causelsl staled s i/ I III \ 1 / l`�` _ MARR a 14a 'USUAL OCCUPATION IG1ve kmdof work done during n l = r*I tab KIND OF BUSINESS INDUSTRY c`02 15 EDUCATION (Speclty only highest grade completed) Elementary j gr � condary (112) College I1 a or 5• I of working IAe . event/retired) Owner /operator a m '� D m !—+ V Samway Alice Hatcher 18 WAS DECEASED EVER IN U S. ARMED FORCES? 19a. INFORMANT - NAME ;Yes no or unk.I Ilf yes give war and dates of services) l No Roger Whitefoot 19b INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN STATE. ZIPI 4235 Vermont Ave., Grand Island, NE. 68801 �R 9'? t/ N D W CEMETERY OR CREMATORY NAME L� ©Burial ❑Removal June 23, 2001 Grand Island Cemetery 22a FUNERAL ME NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes ❑Cremation ❑Donalior Grand Island, NE. till 1123 West Second, Grand Island, NE. 68801 N iJ'1 0 Lot 2, Block 2 of Elm Place Addition to the City of Grand Island, Hall County, NE. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOAD-ON RL£ WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISIXS SUCTION; WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ DATE OF ISSUANCE N 200111835 NLEY& COOPER JUL 2 0 2001 ASSISTANT STATEREGISM" LINCOLN, NEBRASKA HEALTH AND-HUMAN SERVICES SYSTgI STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES PNANCE AND SIPPORT VTTAL STATISTICS _ 0 07044 CERTIFICATE OF DEATH -- 1 DECEDENT NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH /Month Day Yearl Hilda NMN Minor Female' June 19, 2001 a CITY AND STATE OF BIRTH Rf nohn U S.A. name country) (Ages 10 54I Yes No 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH lMonlh. Day Year) Yeovil, England [—I ACUdenl Undele"oed (Yrsl 86 September 29, 1914 Sb MOS DAYS 5d HOURS MINS 7 SOCIAL SECURTIY NUMBER Suicide [] Pendinq 26e INJURY AT WORK Be PLACE OF DEATH 26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 508 -10 -2087 otf�ce bmlding. etc /Specify) HOSPITAL ❑ Inpatient OTHER Nursing Home ❑ ER Outpatient ❑ Residence 80 FACILITY -Name pl not institution, give street and number) I .Lakeview Care Center ❑ DOA ❑ Other /Specify, 8c CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes ❑X No ❑ Hall 9a RESIDENCE -STATE 9th COUNTY I 9c CITY TOWN OR LOCATION 9d STREET AND NIJM1FP (1- 1.ding?rp Code; 9, INSIDE CITY LIMITS Nebraska Hall Grand Island 1411 W. Divison 68801 Yes X❑ No ❑ 10 RACE (a g, Wnite. Black American Ind-an 11. ANCESTRY leg .Italian. Mexican. German, etc) 12 ❑MARRIED W11 OWED t 3 NAME OF SPOUSE 111 wife qne maiden name) etc I (Soeclty) White (Speclfyl English NEVER DIVORCED James Minor causelsl staled s i/ I III \ 1 / l`�` _ MARR (/� .. ISi nature and Tltlel ► 14a 'USUAL OCCUPATION IG1ve kmdof work done during n l tSl nature and (Itle) ► tab KIND OF BUSINESS INDUSTRY 30.a HAS ORGAN OR TISSUE DONATION CONSIDERED? 15 EDUCATION (Speclty only highest grade completed) Elementary j gr � condary (112) College I1 a or 5• I of working IAe . event/retired) Owner /operator Whitefoot Produce 31 NAME AND ADDRESS OF CERTIFIER !PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI 'Type or Print) 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Frederich Samway Alice Hatcher 18 WAS DECEASED EVER IN U S. ARMED FORCES? 19a. INFORMANT - NAME ;Yes no or unk.I Ilf yes give war and dates of services) l No Roger Whitefoot 19b INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN STATE. ZIPI 4235 Vermont Ave., Grand Island, NE. 68801 20. EM ALMER - SIGNATURE 8 LICENSE NO 9'? t/ 21 a. METHOD OF DISPOSITION I 21b. DATE 2tc CEMETERY OR CREMATORY NAME L� ©Burial ❑Removal June 23, 2001 Grand Island Cemetery 22a FUNERAL ME NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes ❑Cremation ❑Donalior Grand Island, NE. 221, FUNERAL HOME ADDRESS (STREET OR P.F.D. NO CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, NE. 68801 I 23 IMMEDIATE CAU61 (tN TIEH UNLY LINE UAUbt FtH LINt, I'UH al. 101. ANU ICI) Interval between onset and death PART / � S I I lal /A//� / V,+,�/C r Vi 6 ` ;--6 Y&-kj DUE TO. OR AS A CONSEQUENCE OF - Interval between onset and death I I (b) DUE T0. OR AS A CONSEQUENCE OF Interval between onset and death Ic) OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART It IF FEMALE. WAS THERE A I 2a AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' II (Ages 10 54I Yes No Yes No yes D No 26a 26th DATE OF INJURY IMo.. Day. Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED - [—I ACUdenl Undele"oed M Suicide [] Pendinq 26e INJURY AT WORK 261 PLACE OF INJURY - At home, tarm, street factory 26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE uHomlatle Investigation Yes No ❑ ❑ otf�ce bmlding. etc /Specify) 27a DATE OF DEATH IMo Day Yrrl 28a DATE SIGNED IMO Day Yr) 28th TIME OF DEATH V, = > ;D 27b. DATE SIGNED (Mo% Oa/y Yr II 27c TIME OF DEATH 28c PRONOUNCED DEAD IMo. Day, Yr.) 28d. PRONOUNCED DEAD /HOUrI J J -o Mme.' w z M 27d To the best of my knowledge e occwred a e time Q�t ace antl due to me 28e. On the basis of examination and or Invesllgahon, in my opinoon death occurred at ° z causelsl staled s i/ I III \ 1 / l`�` _ the time, date and place and due to the cause(s) stated . (/� .. ISi nature and Tltlel ► tSl nature and (Itle) ► _ 29 DID TOBACCO USE CONTTRII7{BUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION CONSIDERED? 30th WAS CONSENT GRANTED' ❑ YES � NO ❑ UNKNOWN jBEEN ❑ YES t NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER !PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI 'Type or Print) David Colan M.D. 729 N. Custer, Grand Island, NE. 68803 32a REGISTRAR 32b DATE FILED BY REGISTRAR (Mo.. Day Yr)