|
S O .4
<br />W -h O-
<br />r rD
<br />~o z
<br />C? rF O
<br />O H
<br />�
<br />O 7
<br />fi G
<br />< H ?.
<br />v rr w
<br />rD -n
<br />Z rD r+
<br />rJ 7 <
<br />2r t
<br />1 .-. to
<br />r rJ
<br />r 7
<br />7,
<br />7 LT
<br />w �R
<br />n v
<br />x
<br />H -h
<br />? tO
<br />3 r+
<br />W O
<br />(� M
<br />n o
<br />t+ r+
<br />a w
<br />0. H
<br />w�
<br />a
<br />7 7
<br />r+
<br />o :a
<br />r{
<br />-- 401
<br />L
<br />C?
<br />O N
<br />� S
<br />C w
<br /><
<br />N '7
<br />s
<br />y v\
<br />� v
<br />Q
<br />h
<br />WHEN TENS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERI /ICES
<br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL _ON FILL WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ - =NCH IS
<br />ljff
<br />DATE OF ISSUANCE 200400987
<br />_
<br />WEYS R
<br />10/24/2003 =
<br />�ISSIST��I�tIiAR
<br />LINCOLN, NEBRASKA HEALTH AWK4L O SERVIZ`E$ bYSWEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN3�R9 $ _ CB�FHI SUPPORT
<br />VITAL STATISTICS
<br />CERTiFTCATR nF nP.A.TFT _ - _ --
<br />1. DECEDENT -NAM FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Yee/)
<br />Roy Henry Rroos
<br />Male
<br />June 8, 2003
<br />4. CITY AND STATE OF BIRTH prnot in USA. name country)
<br />Sa. AGE - Lad Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Marts. Day. Year/
<br />5b. MOS. I DAYS
<br />Sc. HOURS' MINIS.
<br />M
<br />=
<br />D
<br />• 7. SOCIAL SECURTIY NUMBER
<br />go. PUCE OF DEATH
<br />e 507 -38 -5722
<br />HOSPITAL is inpatient OTHER: Nursing Home
<br />__ ❑
<br />11 g . iI f �A f
<br />J �^�'�28b.
<br />❑ ER Oulpatlem ❑ Residence
<br />8b. FACILITY - Name /prior nsaWyd6 Ave stns and number)
<br />e St. Francis Medical Center
<br />-n
<br />C
<br />rn
<br />Nn
<br />Grand Island +YIN ® No ❑
<br />Hall
<br />,
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />rt
<br />9a. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island 12407
<br />N: Locust 68801
<br />Yee No
<br />10. RACE - (e.g., White. Black. American Indian,
<br />11. ANCESTRY le.g.. Italian. Mexican, German, std)
<br />12.'(1 MARRIED ❑ WIDOWED
<br />°
<br />slc.)(speoify) White
<br />nt
<br />NEVER DIVORCED
<br />p
<br />140. USUAL OCCUPATION (Give kindd work done durkg most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working life, even it reared)
<br />Farmer
<br />Agriculture
<br />° D
<br />Yes ❑ No ❑
<br />CL
<br />8
<br />n
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto Rroos
<br />Alma Franzenbur
<br />1 &- WAS DECEASED
<br />`*
<br />19a. INFORMANT -NAME
<br />. (YIN. no, a ludo)
<br />(It yes, give war and dams Of services)
<br />I
<br />I"
<br />�'
<br />Elfriede Kroos
<br />Ift INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2407 N. Locust, Grand Island' Nebraska 68801
<br />20. - SIGNATURE LIC NO.
<br />':1
<br />r
<br />CEMETERY OR CREMATORY NAME
<br />ry
<br />❑Budd ❑ Removal
<br />n
<br />to
<br />22a. ,FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />"'
<br />rn
<br />;_
<br />C:0
<br />M
<br />C:)
<br />VDi
<br />M
<br />a $
<br />o
<br />iF 27d. To the bed of my knowledge occurrotl at e, d }le place and due to Me
<br />+!
<br />� On ate brie of examination and,or investigation, in my opinion death occurred at
<br />C:)
<br />q
<br />\
<br />6
<br />Via tim9, dab and place and due to the cause(sl stated.
<br />(signature and Title) P,
<br />c -_
<br />r9d Tlde ) ►
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />o„
<br />o
<br />N
<br />30.b WAS CONSENT GRANTED?
<br />[BA
<br />( YES ❑ NO ❑ UNKNOWN
<br />❑
<br />YES �p
<br />NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Pnnt)
<br />avid Colan M 7291N.
<br />CUs er
<br />ve. Grand Island NE 68803
<br />REGISTRAR
<br />M. DATE FILED BY REGISTRAR (Mo.. Day. Yr./
<br />JUN 11 2003
<br />v ru,
<br />r
<br />o
<br />(D
<br />CD
<br />�
<br />C.0
<br />00
<br />Z
<br />CID
<br />�]
<br />cn
<br />,v
<br />O
<br />Cn
<br />WHEN TENS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERI /ICES
<br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL _ON FILL WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ - =NCH IS
<br />ljff
<br />DATE OF ISSUANCE 200400987
<br />_
<br />WEYS R
<br />10/24/2003 =
<br />�ISSIST��I�tIiAR
<br />LINCOLN, NEBRASKA HEALTH AWK4L O SERVIZ`E$ bYSWEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN3�R9 $ _ CB�FHI SUPPORT
<br />VITAL STATISTICS
<br />CERTiFTCATR nF nP.A.TFT _ - _ --
<br />1. DECEDENT -NAM FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Yee/)
<br />Roy Henry Rroos
<br />Male
<br />June 8, 2003
<br />4. CITY AND STATE OF BIRTH prnot in USA. name country)
<br />Sa. AGE - Lad Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Marts. Day. Year/
<br />5b. MOS. I DAYS
<br />Sc. HOURS' MINIS.
<br />Grand Island, Nebraska
<br />(Yrs.) 73
<br />March 24, 1930
<br />• 7. SOCIAL SECURTIY NUMBER
<br />go. PUCE OF DEATH
<br />e 507 -38 -5722
<br />HOSPITAL is inpatient OTHER: Nursing Home
<br />__ ❑
<br />11 g . iI f �A f
<br />J �^�'�28b.
<br />❑ ER Oulpatlem ❑ Residence
<br />8b. FACILITY - Name /prior nsaWyd6 Ave stns and number)
<br />e St. Francis Medical Center
<br />❑ DOA ❑ Other /Specify
<br />Sc. CITY, TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island +YIN ® No ❑
<br />Hall
<br />W, RESIDENCE - STATE -
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d STREET AND NUMBER - /kriluit ngZp Cody
<br />9a. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island 12407
<br />N: Locust 68801
<br />Yee No
<br />10. RACE - (e.g., White. Black. American Indian,
<br />11. ANCESTRY le.g.. Italian. Mexican, German, std)
<br />12.'(1 MARRIED ❑ WIDOWED
<br />3. NAME OF SPOUSE /1R wile. giwmaidan name/
<br />slc.)(speoify) White
<br />(sv9dity) German
<br />NEVER DIVORCED
<br />�lfriede Schenk
<br />140. USUAL OCCUPATION (Give kindd work done durkg most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working life, even it reared)
<br />Farmer
<br />Agriculture
<br />Elementary or Secondary 10 -12) College 11 -4 or 5'I
<br />Yes ❑ No ❑
<br />-
<br />1
<br />8
<br />1& FATHER -NAME FIRST MIDDLE a LAST"
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto Rroos
<br />Alma Franzenbur
<br />1 &- WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />. (YIN. no, a ludo)
<br />(It yes, give war and dams Of services)
<br />I
<br />No
<br />I
<br />Elfriede Kroos
<br />Ift INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2407 N. Locust, Grand Island' Nebraska 68801
<br />20. - SIGNATURE LIC NO.
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />iDLMER
<br />4,41 1A Y07•
<br />❑Budd ❑ Removal
<br />June 11 2003
<br />Westlawn CrematoKy
<br />22a. ,FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />®Cremation ❑Donatxrn
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St. Grand Island Nebraska 68801
<br />•• ••-•--- • • - - - -- . - vn 1 -1. _... - ur•c - ". rut, - Icll Interval between onset and death
<br />PART
<br />-3a, i'iI_u AAA"i IAA A,, if 14Zjr k
<br />DUE TO. .0111 AS A CONSEQUENCE OF: ..
<br />sled and Ossa +-
<br />(b)
<br />I•
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Interval between onset and death
<br />I
<br />(c(
<br />125.
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />111 IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />WAS CASE REFERRED TO MEDICAL
<br />11 g . iI f �A f
<br />J �^�'�28b.
<br />( r
<br />1 6 I1 �J
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(/v
<br />(
<br />(Ages 10 -541 Yes No
<br />Yes No
<br />Yes No
<br />2811.
<br />DATE OF INJURY /MaV Oay- Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN, JRY OCCURRED
<br />MAccident F� Undetermined
<br />I
<br />I
<br />Suicide 0 Pending
<br />M
<br />269. INJURY AT WORK
<br />25f. MIN . % RAt tmq , farm, street. factory
<br />56M q sp9�Yi
<br />26g, LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />QHomicide Investigation
<br />Yes ❑ No ❑
<br />-
<br />1
<br />27a. DATE OF DEATH /Ma. Day. Yr,)
<br />2811 DATE SIGNED /Mia. Day. Yr.)
<br />28b. TIME OF DEATH
<br />a
<br />June 8 2003
<br />M
<br />,8
<br />27b. DATE SIGNED /Mo.. Day.
<br />27c. TIME OF DEATH
<br />-
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (yorm
<br />M
<br />a $
<br />M
<br />iF 27d. To the bed of my knowledge occurrotl at e, d }le place and due to Me
<br />+!
<br />� On ate brie of examination and,or investigation, in my opinion death occurred at
<br />causels) stated. n
<br />q
<br />\
<br />6
<br />Via tim9, dab and place and due to the cause(sl stated.
<br />(signature and Title) P,
<br />r9d Tlde ) ►
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />[BA
<br />( YES ❑ NO ❑ UNKNOWN
<br />❑
<br />YES �p
<br />NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Pnnt)
<br />avid Colan M 7291N.
<br />CUs er
<br />ve. Grand Island NE 68803
<br />REGISTRAR
<br />M. DATE FILED BY REGISTRAR (Mo.. Day. Yr./
<br />JUN 11 2003
<br />ME
<br />
|