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200111856 <br />LIEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT-OF HEALTH, <br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON FILE TH `FNE -STATE <br />DEPARTMENT OF HEALTH, BUREAU OF V ?AL STATISTICS, WHICH IS THE LEGAL lQEPOt#S0WR <br />VITAL RECORDS. _ <br />T OF E <br />N ISSU - <br />12 1y9� S.,coavE� <br />ASS % TANT' TE RMISTP AR -- <br />LINCOLN, NEBRASKA NEBRASKA DEPItRTMENF DF /HEALTH= <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH --- - = <br />BUREAU OF VITAL STATISTICS - <br />CERTIFICATE OF DEATH <br />1- DECEDENT -NAME . FIRST MIDDLE LAST <br />2. SExFemal <br />3. DATE OF DEATH /Mont. Day. Pearl <br />Ja=ine Poe Decker <br />Miele <br />1 <br />March 01,1996 <br />4. CITY AND STATE OF BIRTH /andrn USA.. rwrte wt^Vy/ <br />Sa. AGE - Last Birthday <br />UNDER t YEAR <br />UNDER t DAV <br />S. DATE OF BIRTH /Malt. Day. Yew/ <br />(Yra.l 77 <br />January 01, 1919 <br />5b MOS ; DAYS <br />Sc. MINS <br />Missouri Valley, Iowa <br />7. SOCIAL SSECCURRTIIY NUMBER <br />as PLACE OF DEATH <br />507-054712 <br />HOSPITAL: ❑ kpab" OTHER ❑ Nut ng lid. <br />r <br />� ER Ouipm ere ❑ Residence <br />0-b. FACILITY - Nama /tern at vntMktant OW Sass/ and reanbayl <br />St. Francis Medical Center <br />❑ DOA ❑ Dow /sal <br />Be. CITY. TOWN OR LOCATION OF DEATH BD. INSIDE CITY LMTS Be COUNTY OF DEATH <br />Grand Island yB, ® No ❑ Hall <br />- STATE 9b. COUNTY 9c. CTTY. TOMM OR LOCATION 9d STREET AND NUMBER f0icAr0921p cowl 9e INSIDE CITY UWTS <br />Nebraska I Hall Grand Island 1419 North Park Avenue, 68803 Yes 1� No ❑ <br />10. RACE -10.4. WNte. Black. ArMrroan Indian. <br />11. ANCESTRY le.g.. Itelyrr. Merocan. German. aft) <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE IM wM pw naNNn rainy <br />U Ite <br />rMTrican <br />1 <br />NEVER DNORCED <br />Arthur Louis Decker <br />14a. USUAL OCCIIPATON /Give k.rdd was cars arrg indite tlb. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specay onty grade CWM"M <br />d aarvp lN9 owl Novi <br />Church <br />EMrnsM a Secondary 10 -121 Cc" 0.4 or 5.1 <br />S"reta <br />16 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />John Nagel <br />Lula Hatcher <br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />Igo. INFORMANT - NAME <br />(Yea no. a natr,l M yes. 9wa w and doss d mvion) <br />Arthur Decker <br />No <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CRY OR TOWN. STATE. 2IM <br />1419 North Park, Grand Island, Nebraska 68803 <br />20.E - SIDNA i LICEN%E <br />210- METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />#1071 <br />03/04/19% <br />Westlawn Memorial Park Cemeter, <br />Bun a ❑ Ra-w <br />F - <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel-Butler- Geddes Funeral Home <br />❑ Chat. ❑ Ddna.dn <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />M. MEDIATE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (cll Interval between area and death <br />PSI <br />l l 1. N/V � I. =d e f <br />DUE TO. OR AS A CONSEQUENCE OF Inwval between onea and death <br />� I <br />I <br />(b) <br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions wneibulrq b to death but not related <br />PART a IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />125, REFERRED TO MEDICAL <br />PART <br />PREGNANCY IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER'S <br />N <br />(Ages 10-541 Yes No <br />Yes p No al <br />Yes No <br />269, <br />26b. DATE OF INJURY /MO.. Day. Yr./ <br />26c. HOUR OF INJURY tad DESCRIBE HOW INJURY OCCURRED <br />0 Accident F� Undawnrad <br />._ <br />_twn�p <br />M <br />S aside � Pandirrg <br />269. INJURY AT WORK <br />261. PLACE OF 8U Y /At . farm. street- factory <br />dkc bukanQ SpscAy <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />Homicide Inwevestig.9on <br />Vas ❑ No ❑ <br />-- <br />•` <br />270- DATE OF DEATH /Ma. Day Yr.) <br />26a DATE SIGNED (Ma.. Day. Yr l <br />28o TIME OF DEATH <br />a� <br />March 1 1996 <br />M <br />27b DATE SIGNED /Mo. Day YrI <br />27c. TIME OF DEATH [ i- <br />28c PRONOUNCED DEAD /MO. Day. Yr.) <br />28d. PRONOUNCED DEAD (hour) <br />i <br />k <br />E <br />" -3 4 Q L <br />M <br />H i <br />M <br />27d To the beat d my krwrMdge. de occurred a the time, dam and place and due Id tte <br />28e On the basis of examination and on i vesogason. in my opinion death occurred at <br />v <br />` <br />cause(s) stiaed. <br />a <br />are time, date and place and due to the cause a) stated. <br />( a and Tde <br />I and Tilt <br />DID TOBACCO USE CONTRIBUTE TOT DEA ? 30.0- <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDn 30.b <br />WAS CONSENT GRANTED' <br />129 <br />UNKNOWN <br />❑ YES ❑ NO UNKNOWN <br />9-YES r] <br />❑ YES NO <br />31 M ND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type o PnnO <br />` A; /- `7 s� ��-. <br />«< �, w • � w•s 0 () w 3! ►fie & <br />32a REGISTRAR 4Z4 X <br />. &0k, <br />32b DATE FILWr jrIST t /Ab1yy.Yr) <br />Ar E <br />