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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SYSTEA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE NOV 14 2001 LINCOLN, NEBRASKA 200 112 4 8 �EALTH A =} STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HU AF:-SER VITAL STATISTICS _ i.nn•s•ralrn A TC r%V nIC A'fT.i' -- WITH A 01 06006 I DECEDENT - NAME FIRST MIDDLE LAST 2. SER - J DATE OF DEATH lMonrrl. Day. Year) Steven Ladd Cromer Male b) May 19, 2001 4. CITY AND STATE OF BIRTH II /no! m OS. A.. name country] Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 7 DAY 6. DATE OF BIRTH /MOWN. Day Year1 (Vrs.l 5b. MOS. i DAYS Sc.HOURS' 48 MINS Tu t 12 1952 C1 Kearney, Nebraska FEMALE. 3 MONTHS? 7 SOCIAL SECURTIV NUMBER Be . PLACE OF DEATH � OTHER ❑ Nursing Home 505 -62 -4226 HOSPITAL' Inpatient -_� ❑ ER Outpatient Bb FACILITY - Name /H nor mstitutiort, give street and numbed ❑ Residence ❑ ❑ DOA Omer /Specdvl St. Francis Medical Center 26c. HOUR OF Bc CITY TOWN OR LOCATION OF DEATH Br). INSIDE CITY LIMIT $ -Be COUNTY OF DEATH _ Grand Island Y NO ❑ Hall 9a RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zp Codel 9e INSIDE CITY LIMITS Nebraska Hall Cairo 605 Oasis Pl. 68824 Yes ® No ❑ I O RACE - le.g., White. Black. American Indian 11. ANCESTRY leg, Italian. Mexican, German, etc) 12 ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /I/ wrle . give maden name! etc .I (Soecily)White (SpecilylGerman NEVER DIVORCED Cheryl Oltman l7C MARRI 14a USUAL OCCUPATION lGrve kind of work done owing most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -121 College 1 -a or 5.1 r of working (Ile, even it renredl Dentist Medical + 16. FATHER -NAME FIRST MIDDLE LAST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME Chalmers Cromer Ruth Bach.Tan 16 "/AS DECEASED EVER IN U 5 ARMED FORCES? 19a. INFORMANT - NAME - ° �c 28e. On the basis of examination and or investigatbn, n my opinion deem occurred at ~ a date due to the cause(s) stated. IY 6,, or unk.( III yes. give war and dates of services) I ��JJ Cheryl Cromer (Si nature and Title, ► ( nature and Tore ► 29. DID TOBACCO USE CONTRIBUTE TO THE H? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 -b WAS CONSENT GRANTED? 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP] _ ❑ YES D4 ❑ YES NO I P.O. Box 190 Cairo, NE 68824 20 EM ER - NATU ICENSE N 21a. METHOD OF DISPOSITION 210. DATE i 2tc. CEMETERY OR CREMATORY NAME lam' ® ❑ 5/23/01 Mt. Pleasant Cemetery 1 2 7_!W� Burial Removal 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 22. . F L HOME -NAME fel Funeral Home ❑ Cremation 0 Dona''°^ Cairo, NE 22b FUNERAL HOME ADDRESS IS I REE I OR R.F.D. NO., CITY OR TOWN. STATE, ZIP( 411 West 11th St. P.O. Box 126 Wood River, NE 68883 _....... ,." < ,., - .- -I I Interval between onset and death 23 GAVJt PART \�u _ lal M �- I Interval be onset and death DUE TO, OR AS A CONSEOUENCE OF V V b) Interval between onset and death DUE TO.-OFFAS A CONSWU NC OF cl O SIGNIFICANT CONDITIONS - Conditions contripiAng to the death but not related FEMALE. 3 MONTHS? 24 AUTOPSY MEDICAL 25. EXAMINER WAS CASE OR CORONER' PART If , ' \ t No Yes No Yes No 26a. 26b. DATE OF Y (Mo.. Day. Yr) 26c. HOUR OF INJURY OCCURRED Accident � Undetermined 26e. INJURY ARK 7N. eRY 1At dome, 261. Weft farm. street. factor/ 260. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE Q. Suicide F1 Pending EHomicide Investigation yes ❑ ❑ u�ld� 27a DATE OF DEATH /Mo.. Day. Yrl 28a. DATE SIGNED /Mo.. Day. Yr.) 28b. TIME OF DEATH May 19, 2001 sag M N 27b. DATE SIGNED (Mo. Day. yr.) 27c. TIME OF DEATH 2Bc. PRONOUNCED DEAD IMO. Day, YO 28d. PRONOUNCED DEAD (Hour) ` j d �� May 5:35 pm_._. M w =� M g�� �9 27d. To the best d my krowNedge. de occurred at time, dat and d ce and due to the b ° �c 28e. On the basis of examination and or investigatbn, n my opinion deem occurred at ~ a date due to the cause(s) stated. < cauhe stated. ° the time, and place and (Si nature and Title, ► ( nature and Tore ► 29. DID TOBACCO USE CONTRIBUTE TO THE H? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 -b WAS CONSENT GRANTED? �No ❑ YES D4 ❑ YES NO ❑ YES UNKNOWN 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Pr/nf/ ` Dr Ryan D Crouch DO 800 A pha Grand Island,'NE 68803 yr) 32D. o. Day YrJ 32a REGISTRAR A. . j t� 1 2 7_!W� u Re:Lots Four (4), and Five (5), Weber Subdivision, City of Cairo, Hall County, Nebraska, and The Westerly One Hundred Feet (100') of the Southerly Twenty -Three Feet (23') of Lot Five (5), Block Six (6), Original Town of Cairo, Hall County, Nebraska.