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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND-HL
<br />SYSTEM, R CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGM
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VIT,IL S*Wk 7,9t(
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 2 0 0111918 = -X
<br />AUG 3 12000
<br />LINCOLN, NEBRASKA HEAL HI# #iU lINSE1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HL3A4AA�RI
<br />VITAL STATISTICS
<br />CERTIFICATE, OF T)F.AtkF ==
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<br />iiPART & J A ,i.rf I &WrlA 1
<br />A CONSEQUENCE OF
<br />I A A_ A
<br />(bf
<br />T GA I -r75
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Icl (4 -1 AAJ l f, 4 t- 0_4-,&) el
<br />Interval between onset and nealn
<br />G1-94
<br />Interval between onset and death
<br />I r�
<br />Interval between onset and death
<br />_y r %0 If (
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />1 Df CFDENT NAME FIRST MIDDLE LAST
<br />2. SEX 3 DATE OF DEATH (MoWn it,t1 year:
<br />25 WAS CASE REFERR D TO MEDICAL
<br />CD
<br />Female August 21, 2000
<br />d. CITY AND STATE OF BIRTH Ill not o USA name country)
<br />SD
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH 1Montn Dav Year)
<br />Cozad, Nebraska
<br />O
<br />February 7, 1922
<br />Sb MOS DAYS
<br />Sc. HOURS MINS
<br />�
<br />Ba PLACE OF DEATH - -- -
<br />O
<br />COD
<br />O
<br />Bb FACILITY - Name ll1 nor institution, give street and number)
<br />Good Samaritan Center
<br />❑ DOA ❑ Oherspecity _ - -- ___
<br />Oc CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS I Be COUNTY OF DEATH
<br />rJ
<br />..was Y Nd Q., Hall
<br />F-]
<br />y¢s No
<br />9a RESIDENCE - STATE 19b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER (including Zip Code( 9e INSIDE CITY LIMITS
<br />CAD
<br />Nebraska Hall
<br />Grand Island
<br />1007 S. Eugene 68801 Yes ® Nd ❑
<br />10 RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY le g.. Italian. Mexican. German, etc)
<br />12. [-]MARRIED f-7 WIDOWED
<br />IX-1
<br />13 NAME OF SPOUSE !fl wfe give maiden name)
<br />MR
<br />pry, _° _'""' mixron ciry- wive crux rcn 1-1-r 'al lot, -Icll
<br />iiPART & J A ,i.rf I &WrlA 1
<br />A CONSEQUENCE OF
<br />I A A_ A
<br />(bf
<br />T GA I -r75
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Icl (4 -1 AAJ l f, 4 t- 0_4-,&) el
<br />Interval between onset and nealn
<br />G1-94
<br />Interval between onset and death
<br />I r�
<br />Interval between onset and death
<br />_y r %0 If (
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />1 Df CFDENT NAME FIRST MIDDLE LAST
<br />2. SEX 3 DATE OF DEATH (MoWn it,t1 year:
<br />25 WAS CASE REFERR D TO MEDICAL
<br />Dorothy Alice Jordan
<br />Female August 21, 2000
<br />d. CITY AND STATE OF BIRTH Ill not o USA name country)
<br />S. AGE Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH 1Montn Dav Year)
<br />Cozad, Nebraska
<br />IVrsl
<br />78
<br />February 7, 1922
<br />Sb MOS DAYS
<br />Sc. HOURS MINS
<br />7 SOCIAL SECURTIV NUMBER
<br />Ba PLACE OF DEATH - -- -
<br />481 -14 -2027
<br />HOSPITAL ❑ Inpatient OTHER Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Bb FACILITY - Name ll1 nor institution, give street and number)
<br />Good Samaritan Center
<br />❑ DOA ❑ Oherspecity _ - -- ___
<br />Oc CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS I Be COUNTY OF DEATH
<br />wood.. River ._. _
<br />..was Y Nd Q., Hall
<br />F-]
<br />y¢s No
<br />9a RESIDENCE - STATE 19b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER (including Zip Code( 9e INSIDE CITY LIMITS
<br />27a DATE OF DEATH (MO. Day Yr.)
<br />Nebraska Hall
<br />Grand Island
<br />1007 S. Eugene 68801 Yes ® Nd ❑
<br />10 RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY le g.. Italian. Mexican. German, etc)
<br />12. [-]MARRIED f-7 WIDOWED
<br />IX-1
<br />13 NAME OF SPOUSE !fl wfe give maiden name)
<br />etc .I (Specify)
<br />White
<br />(Spec. yl
<br />American
<br />NEVER
<br />MEVE DIVORCED
<br />Bernard Frank Jordan (DE
<br />tda USUAL OCCUPATION /Give kindof work done during most
<br />tab KIND OF BUSINESS INDUSTRY
<br />EDUCATION IS only highest grade completed)
<br />of working life, even d refired(
<br />Dental Assistant
<br />Dental Care Office
<br />_
<br />TElemedlary or Secondary f0 121 College it ad, 5
<br />2 Years
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />B
<br />'Benjamin _ Ganow
<br />F Nettie Spain
<br />18 WAS DECEASED
<br />EVER IN U S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes do or unk,l
<br />III yes give war and dates of services)
<br />Ji
<br />No
<br />-- - - - - --
<br />Tom Jordan
<br />°
<br />( 19b INFORMANT MAILING ADDRESS (STREET OR R F D NO CITY OR TOWN STATE. ZIPI
<br />408 W. 13th St., Grand Island, NE 68801
<br />20 - ALMER SIGNATURE 8 LICENSE NO
<br />21a. METHODOF DISPOSITION
<br />I 21b. DATE 21C CEMETERY OR CREMATORY NAME
<br />WAS CONSENT GRANTED'
<br />X ❑ YES NC ❑ UNKNOWN
<br />Burial ❑ Removal
<br />Aug. 24, 2000 I Grand Island City Cemetery
<br />Va FUNERAL HOME NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNT((Y�1ATTORNEYI (Type aP_ri,�
<br />` T /�--+ / r f
<br />Livingston - Sondermann F.H.
<br />❑Cremation ❑DionaIIOn
<br />Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F 0 NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, NE 68803 -4050
<br />MR
<br />pry, _° _'""' mixron ciry- wive crux rcn 1-1-r 'al lot, -Icll
<br />iiPART & J A ,i.rf I &WrlA 1
<br />A CONSEQUENCE OF
<br />I A A_ A
<br />(bf
<br />T GA I -r75
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Icl (4 -1 AAJ l f, 4 t- 0_4-,&) el
<br />Interval between onset and nealn
<br />G1-94
<br />Interval between onset and death
<br />I r�
<br />Interval between onset and death
<br />_y r %0 If (
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25 WAS CASE REFERR D TO MEDICAL
<br />PREGNANCY
<br />IN THE PAST 3 MONTHSn
<br />.r
<br />EXAMINER OR CORONER'
<br />II
<br />_
<br />(Ages 10 -541 Yes No
<br />Ves No
<br />_ Yee No
<br />26a
<br />26b DATE OF INJURY lMo Day Yr)
<br />26C HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />u Accident u Undele,m ed
<br />M
<br />Suicide Pending
<br />26e INJURY AT WORK
<br />26t PLACE OF INJURY - At home. farm. street. factory
<br />office budding. etc !Speciry)
<br />26g. LOCATION STREET OR R F D NO CITY OR TOWN STATE
<br />HOmrClde Investigation
<br />a❑
<br />F-]
<br />y¢s No
<br />27a DATE OF DEATH (MO. Day Yr.)
<br />28a DATE SIGNED lMO. Day Yr;
<br />28b TIME OF DEATH
<br />271b . DATE SIGNED lMo. Day. nl
<br />127c. TIME IF DEATH
<br />28c PRONOUNCED DEAD (Mo Day. Yr.)
<br />28d PRONOUNCED DEAD lHourl
<br />27tl TO the best of my knpwledg¢ h occurred a, time, date . D e and due to the
<br />28e. On the basis of examination and or investigation, In my opinion deam -cuued at
<br />Ji
<br />° ¢ cut
<br />,r cause(s) slated `
<br />°
<br />the time, date and place and due to the causelsl stated.
<br />!SI nature and Title) ►
<br />ISI nature and T,tlej I)
<br />29 DIO TOBACCO USE CONTRIBUTE TO THE DEATH>
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CON
<br />WAS CONSENT GRANTED'
<br />X ❑ YES NC ❑ UNKNOWN
<br />1 ❑ YES NO
<br />❑ YES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNT((Y�1ATTORNEYI (Type aP_ri,�
<br />` T /�--+ / r f
<br />32a REGISTRAR I
<br />32b DATE FILED BVREGIS7gq,RG/M OTYr2000
<br />C
<br />(/ v
<br />LEGAL; Lot Two (2), in Block Ten (10), in Claussen Country View Addition
<br />to the city of Grand Island, Hall County, Nebraska
<br />
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