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LEGAL DESCRIPTION:
<br />Unit Eleven (11), Oakwood Condominiums in the City of Grand Island, Hall County,
<br />Nebraska.
<br />WHEN THIS COPY CARL S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGDRD•SR €X WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7IST 1C9_SECR0A9 M0W_ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />OR 12 tow 200112079 ASSISTANT bf���8� RAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSIt*
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC_ INAN , ES-F�[! SUPFURT
<br />VITAL STATISTICS = n ^ ^
<br />f V D'r1P1r A'I'R ii nP A Ti7
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Mont. Day. Year/
<br />M
<br />Female '
<br />February 23, 2001
<br />n "'k
<br />5a. AGE, Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day Year)
<br />5b MOS DAYS
<br />5c. HOURS MINS
<br />Scottsbluff, Nebraska
<br />M
<br />October 20, 1927
<br />7. SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />568 -26 -6466
<br />HOSPITAL: ❑ Inpatient OTHER © Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Ifriot institution. give street and number)
<br />Tiffany Square
<br />❑ DOA ❑ other (spec'"'
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Sit INSIDE CITY LIMITS
<br />T
<br />Grand Island, Nebraska
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />C->
<br />9d. STREET AND NUMBER /Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2828 Lakewood Circle
<br />Yee ® Nb ❑
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY leg. Italian. Mexican, German. etcl
<br />t 2. ❑X MARRIED ❑ WIDOWED
<br />D
<br />atal lSOaciry) White
<br />u J
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<br />14a. USUAL OCCUPATION /Give kindot work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15, EDUCATION
<br />ISpecity, only highest grade completed)
<br />1 1 Elementary or Secondary (0 -121 College 11 -4 or 5.1
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<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
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<br />19a INFORMANT - NAME
<br />(Ye 0 or unk.l I" gas. glue war a. tlates of services)
<br />1�o
<br />Carol Prichett
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<br />.In
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES NO El UNKNOWN
<br />❑ YES ,
<br />NO
<br />❑ YES NO
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<br />LEGAL DESCRIPTION:
<br />Unit Eleven (11), Oakwood Condominiums in the City of Grand Island, Hall County,
<br />Nebraska.
<br />WHEN THIS COPY CARL S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGDRD•SR €X WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7IST 1C9_SECR0A9 M0W_ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />OR 12 tow 200112079 ASSISTANT bf���8� RAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSIt*
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC_ INAN , ES-F�[! SUPFURT
<br />VITAL STATISTICS = n ^ ^
<br />f V D'r1P1r A'I'R ii nP A Ti7
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Mont. Day. Year/
<br />Esther NMI Cler
<br />Female '
<br />February 23, 2001
<br />4. CITY AND STATE OF BIRTH /If not m U S.A.. name country)
<br />5a. AGE, Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day Year)
<br />5b MOS DAYS
<br />5c. HOURS MINS
<br />Scottsbluff, Nebraska
<br />(YrsI 73
<br />October 20, 1927
<br />7. SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />568 -26 -6466
<br />HOSPITAL: ❑ Inpatient OTHER © Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Ifriot institution. give street and number)
<br />Tiffany Square
<br />❑ DOA ❑ other (spec'"'
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Sit INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2828 Lakewood Circle
<br />Yee ® Nb ❑
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY leg. Italian. Mexican, German. etcl
<br />t 2. ❑X MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /I/ wile. give maiden name)
<br />atal lSOaciry) White
<br />ls0eC1 "l American
<br />I
<br />NEVER DIVORCED
<br />John Cler
<br />14a. USUAL OCCUPATION /Give kindot work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15, EDUCATION
<br />ISpecity, only highest grade completed)
<br />1 1 Elementary or Secondary (0 -121 College 11 -4 or 5.1
<br />of working life. even if rekredl Homemaker
<br />Domestic
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Knaub
<br />Lena Green
<br />F
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />(Ye 0 or unk.l I" gas. glue war a. tlates of services)
<br />1�o
<br />Carol Prichett
<br />i 190 1NYUHMANI MAILINU AUUHCJb 1.1 nttl Vn n.r u. rvV., VIIV Vn IVry rv. �i nlc. �Irl
<br />11645,@ii-lette,_OvetAnd Park, Kansas 66210
<br />131 NAMt ANU AUUHt,J OF VtH I lhItH iY"y Jl.IAN. L.UHUNCH J YMy JA WN L1n UUVN I T A I l Vnrvc r I I IYPa U r -nrrr,
<br />David R. Colan, M.D. 729 North C ster , grapid
<br />72a. REGISTRAR Z _ 32b. DATE FILED BY REGISTRAR /Md.. Day. yr/
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<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21c CEMETERY OR CREMATORY NAME
<br />z2K
<br />® Burial ❑ Removal
<br />2/27/2001
<br />Westlawn Memorial Park
<br />O - NAM
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />&ZrERAL
<br />fLel Butler - Geddes
<br />❑ Cremalion ❑ Donallon
<br />3826 W. Stolley Park Rd. Grand Island NE
<br />2b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 W. Second Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND Icll 1 Interval between onset and deal'
<br />PART �///� /� () �e /� Y/
<br />1 (a) 'r /
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death
<br />(D) I
<br />DUE TO. OR AS A CONSEQUENCE OF 1 Interval between onset and death
<br />I
<br />I
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but rot related PART
<br />PART PREGNANCY
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yes -d-gi
<br />Yes M NO
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />F] Accident F-] Undetermined
<br />M
<br />OSuicide El Pending
<br />n
<br />,lJ Homicide Investigation
<br />26e INJURY AT WORK
<br />Yes ❑ No ❑
<br />261. PLACE OFINJURY /S�grr. farm. street factory
<br />ce buIW1
<br />26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED /Mo.. Day. Yr I
<br />28b. TIME OF DEATH
<br />as
<br />€
<br />February 23, 2001
<br />A 5w
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<br />27b. DATE ^SIGNED/ ^� /Mo. y. Yr)
<br />27c. TIME OF DEATH ---�
<br />u u ID M
<br />28c. PRONOUNCED DEAD /Ma. Day. Yr)
<br />28d. PRONOUNCED DEAD /Hourl
<br />M
<br />cause(s) stated.
<br />27d. To the best of my knoVL--M
<br />place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(sl stated.
<br />(S. nature and Title ►
<br />SI nature and Title ►
<br />29. DID TOBACCO USE CONTRIB11TE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BE
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES NO El UNKNOWN
<br />❑ YES ,
<br />NO
<br />❑ YES NO
<br />131 NAMt ANU AUUHt,J OF VtH I lhItH iY"y Jl.IAN. L.UHUNCH J YMy JA WN L1n UUVN I T A I l Vnrvc r I I IYPa U r -nrrr,
<br />David R. Colan, M.D. 729 North C ster , grapid
<br />72a. REGISTRAR Z _ 32b. DATE FILED BY REGISTRAR /Md.. Day. yr/
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