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Rev 1,94 <br />C <br />0 <br />O <br />U <br />T <br />C <br />7 <br />O <br />U <br />O <br />N <br />E <br />W <br />X <br />a) <br />I° <br />Z E <br />W <br />p C <br />W ro <br />U _Y <br />W D <br />� L <br />LL. a <br />0.0 <br />W (D <br />G N <br />Q a <br />Z LL <br />M <br />co <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH 0 i i `� 12 9 <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />I DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />3 DATE OF DEATH ,Monlh Uav veal <br />Tell Henry Perrelet <br />ale <br />June 18 1997 <br />d. CITY AND STATE OF BIRTH (Ifnot in US.A.. name country) <br />So. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAY <br />16 . DATE OF BIRTH (Month Dav year) <br />IN THE PAST 3 MONTHS? <br />(Y's') <br />EXAMINER OR CORONER' <br />I n FA <br />Sb. MOS DAYS <br />5c. HOURS! MINS <br />Lillis, Kansas <br />70 <br />I <br />April 26, 1927_ <br />7 SOCIAL SECURTIY NUMBER <br />._ _ <br />8a. PLACE OF DEATH <br />514 20 7769 <br />HOSPITAL: © Inpatient OTHER ❑ Nursmq Home <br />- -- - <br />❑ ER Outpatient ❑ ResiArm- <br />Bb. FACILITY Name flf nnlmslRufion. give skeel andnunlberl <br />VA Medical Center <br />❑ DOA ❑ olhmfspealy,___ <br />_____. <br />8c CITY TOWN OR LOCATION OF DEATH <br />INSIDE CITY LIMITS <br />tie. COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />r <br />Hall <br />Yes ❑ No ❑ <br />9a RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER Ilncluding Lp Code! <br />9e IN CITY UrdltS <br />26a. UA1E SIGNED fmc, Day. Y,.1 <br />Nebraska <br />Hall <br />Grand Island <br />2330 N Sheridan 68803 <br />Yes ® Ito ❑ <br />M -- <br />10. RACE (e.g., White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian, Mexican. German, elcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (it wile. p,ve maiden name) <br />etc .I !Specify) <br />White <br />(Specilyl <br />French /Swiss <br />NEVER DIVORCED <br />Frances .Gunsolle <br />148 . USUAL OCCUPATION (G,ve kindof work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />115 . EDUCATION <br />(Specify only highest grade completed) <br />__ <br />El to or Secondary 10 12) College n.f n1 i• <br />If working hfe. evendrdNed) <br />Printer <br />Commercial Printing <br />12th �rade <br />16. FATHER - NAME FIRST MIDDLE LAST <br />17 MOTHER FIRSr MIDDLE MAIDEN SURNAME <br />(dec.) Henry Tell Perrelet 1 <br />dec. Annabelle Bealas <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no. or unk.) pl yes. give war and dates of services) <br />Yes WWII/11- 25- 44/1•- 23- -:45 <br />Frances Perrelet <br />(Signature and Title <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIPI <br />DID TOIIA�CCO USE CONTRIBUTE THE D TH7 <br />2330 N. Sheridan Grand.Island, NE 68801 <br />30.b WAS CONSENT GRANT E07 <br />20 EMBALMER - SIGNATURE b LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b, DATE - 21C <br />CEMETERY OR CREMATORY NAME <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P-1) <br />Steven Husen, MD, VA Medical Center 2201,1N Btoadwell Ave Grand Island NE 68803 <br />Service <br />32s. REGISTRAR <br />Not Embalmed <br />Burial Removal <br />❑ ❑ <br />a Cremes h i nn <br />22a FUNERAL HOME NAME <br />21d. CEMETERY ORCREMA70RY LOCATION Cl IV OR TOWN STAIF <br />Cremation ❑Donation <br />Kleine Funeral Home <br />- <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP( <br />3213 W. North Front Street Grand I.slandi Nebraska <br />PART <br />'lal ReSDiratory Failure 2 Months _- <br />DUE TO, OR AS A CONSEQUENCE OF I Inter,al between onset -n naa, <br />Pnd Stage Chtonic Obstructive Pulmonary Disease Years <br />DUE TO, OR AS A CONSEQUENCE OF Imerral bero,een onset a,n noes,, <br />(plLong Term Tabacco Abuse Years <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />2a AUTOPSY <br />- <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IT ASCVD, Cancer, Hypertension <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />I n FA <br />(Ages 10 -54) Yes n No <br />Yes <br />Yes No <br />26a. <br />26b, DATE OF INJURY (Mo.. Day. Yrj <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />F] Accident ❑ Undetermined <br />Suicide Pending <br />26e. INJURY AT WORK <br />281 PLACE O�II�NJB,RY %At 110 T. term, street, factory <br />L SPec <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />office <br />27. DATE OF DEATH jMo.. Day Yr.) <br />26a. UA1E SIGNED fmc, Day. Y,.1 <br />28b 11IAE OF DEATH <br />a <br />June 13 1997 <br />M -- <br />27b. DATE SIGNED fMo.. Day. Yrl <br />27c. TIME OF EATH <br />28c. PRONOUNCED DEAD IMO.. Day. Yr) <br />28d. PRONOUNCED DEAD IHnurl <br />June 18 1 <br />M <br />M <br />s <br />s <br />'S <br />° <br />27d. To the best of my knowledge troccurre le rid place and due 10 the <br />28e. On the basis of examination and /or Investigation, in my opinion death occurred at <br />causelsl staled. <br />h <br />the time, date and place and due to the causes) slated. <br />(Si ,,lure and Title <br />(Signature and Title <br />DID TOIIA�CCO USE CONTRIBUTE THE D TH7 <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANT E07 <br />129 <br />I !>! YES ❑ NO ❑ UNKNOWN <br />❑ YES ® NO <br />❑ YES 1X:1 NO - - <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P-1) <br />Steven Husen, MD, VA Medical Center 2201,1N Btoadwell Ave Grand Island NE 68803 <br />32s. REGISTRAR <br />32b DATE FILED BY REGISTRAR fMo.. Day. Yr) <br />