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WHEN THIS COPYCARItE:S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HI AtA'O RVIE SATEIK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC9l�071Fi 1N THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1STl! THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE { °* DEC 2 7 2002 200401507 ASSISTANT LINCOLN, NEBRASKA HEALTH AND H STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN Ste_-'. VITAL STATISTICS - rRR TTFTr A TF OF nF -A TH �S RT n? 1aRf�► 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day Year/ Roy E. Hofrichter Male December 2 2002 4. CITY AND STATE OF BIRTH (If not in U.S.A.. name country) 68801 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) 51b, MOS. i DAYS Sc. HOURS' MINS. Bellwood Nebraska (Yrs.l 93 March 11 1909 7. SOCIAL SECURTIY NUMBER ❑ Removal Sa. PLACE OF DEATH Homicide Investigation Wood River Cemetery 22a FUNERAL HOME -NAME HOSPITAL: 'E Inpatient OTHER. Nursing Home 507-34-6377 ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (If nor institution, give street and number) St. Francis Skilled Care ❑ Donation ❑ DOA ❑ Oher(SpecAyl 6c CITY TOWN OR I OCA TInN OF DFATH Y Grand Island M I Yes [X] NoE]j Hall 9a. RESIDENCE -STATE 9b. COUNTY 2Bc. PRONOUNCED DEAD (Mo. Day. Yc) 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zp Co, e/ 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 12511 Lakewood Drive Yes ® No ❑ 10. RACE - le.g., White. Black. American Indian, 11. ANCESTRY leg,. Italian. Mexican, German, etc) 12. IN MARRIED ❑ WIDOWED 13. NAME OF SPOUSE fit wife. give maiden name/ etc.) ISpecilyL, (Nril�an 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' RI DIVORCED Wanda Robinson yyjl lte 37. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) Steven L. Husen M.D. 2116 W. FaidlV Ave., #400, Grand Island, NE. 68803 MAR 32b DATE FILED BY REGISTRAR (Mo. Day. Yr) �, 14a. USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 16. EDUCATION )Specify only highest grade completed) Elementary or Secondary (0 -12) College It -4 or 5�1 of working life, even ifretwedl IAgriculture Farmer i 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Edward C. Hofrichter Etta Mae Smith 18. WAS DECEASED EVER IN U.S. ARMED FORCES? ___j 19a. INFORMANT - NAME )Yes. no. or unk.l Ilf yes. give war and Oates of services) No Precious Reed 19b. INFUHMANI MAIL-AUUM- tJ I nccI 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? ero _ II � C r n 1 lcLl i I,6 acw nccd Q e- 2511 Lakewood Drive Grand Island NE 68801 26b. DATE OF JURY (Mo.. Day. Yc/ 26c. HOUR OF URY 20. EMBALMER - SIGNATURE 8 LICENSE NO Accident � Undetermined 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME Not Embalmed ❑ S.,clde ❑ Pending ® Burial ❑ Removal 12 2 02 Homicide Investigation Wood River Cemetery 22a FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ar,foT TPl mora 1 T-Tnrtta ❑ Cremation ❑ Donation 28a, DATE SIGNED (MO. Day Yr.l Wood River. NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) 411 West 11th St. P.O. Box 126 Wood River NE 68883 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)) Interval between onset and death PART rori'ihQ e I I,a)� +QSf��'� C��C�noid �Gcn�or DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death I (b) I DUE TO.OR AS A CONSEQUENCE OF: Interval between onset and death I I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART A� sC.1er0 b G L%O {�B /? Q �y vQ ✓� � /ar PREGNANCY III IF FEMALE, WAS THERE A IN THE PAST 3 MONTHS? 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? ero _ II � C r n 1 lcLl i I,6 acw nccd Q e- (Ages 10 -54) Yes n No Yes M No Yes D No 25a. 26b. DATE OF JURY (Mo.. Day. Yc/ 26c. HOUR OF URY DESCRIBE HOW INJURY OCCURRED Accident � Undetermined 126d. (�� M ❑ S.,clde ❑ Pending 26e. INJU Y AT WORK 261. e b QFFi IINNJeURY At h M farm. sweet. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ 08 oR 27a. DATE OF DEATH (Mo.. Day Ycl 28a, DATE SIGNED (MO. Day Yr.l 28b. TIME OF DEATH M y 61 > a i ° a 27b. DATE SIGNED (Mo. Day. Yr) 27c. TIME OF DEATH 2Bc. PRONOUNCED DEAD (Mo. Day. Yc) 28d: PRONOUNCED DEAD (Noun E d 'S ° /x ?•/7 -D� /. ?5 AM y �E M S F ° ° ° ° 27d. To the best of my kn dge. deyh June e, nd la and due to the 28e. On the basis of examination and %or investigation, In my opinion death occurred al the nine, date and place and due to the causes) stated causelsl stated. �A1 . /^', (Signature and Title ► / V Y�� (Signature and Title) ► 29. DID TOBACCO USE CONTRIB TE TO THE D 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED? ❑ YES NO ❑ UNKNOWN ❑ YES L� "0 ❑ VES t -I O - 37. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) Steven L. Husen M.D. 2116 W. FaidlV Ave., #400, Grand Island, NE. 68803 32a REGISTRAR 32b DATE FILED BY REGISTRAR (Mo. Day. Yr) �, D E C 2 2002