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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL-.P
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAY".
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE AP y
<br />DEC 3 2001 200112 5 2 5
<br />LINCOLN, NEBRASKA HEALTH Al
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAIFW .
<br />VITAL STATISTICS
<br />i-VID TTT+Tr A TA n1P TIT? A 7L �
<br />SERVICES
<br />® f E WITH'
<br />3..WNICH /S
<br />W5,1 `� R
<br />_ 00M r
<br />�Py4iVCe`A1tiI±JPPURT
<br />01 06191
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX ':',
<br />3. DATE OF DEATH /Mont. Day. Veer/
<br />Warren Rex Rollstin
<br />Male
<br />May 24, 2001
<br />4, CITY AND STATE OF BIRTH (ll not in USA.. name country)
<br />-Last
<br />UNDER t YEAR
<br />r'M
<br />6. DATE OF BIRTH /Mont. Day Year;
<br />MOS. DAYS
<br />Sc.HOURS MINS.
<br />Jul 14 1915
<br />Trumbull, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />OF DEATH
<br />0
<br />m
<br />OSPITAL Inpatient OTHER Nursing Home
<br />ER Outpatient Re9dence
<br />8b. FACILITY - Name (If not mshfutiod, give street and
<br />1716 North Park
<br />CD
<br />Bc CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />c
<br />Grand T"sl:AtO t' `-` �. -_ .., _
<br />rDi)
<br />Hall
<br />go. RESIDENCE -STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />CD
<br />z
<br />D
<br />a
<br />Grand Island
<br />1716 North Park 68803
<br />Yea ® No
<br />°
<br />o
<br />o�
<br />fec.I ISPecifyl
<br />White
<br />_
<br />NEVER DIVORCED
<br />,
<br />Nelda Bliss Curtis
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION
<br />(Specify only highest g,.de competed)
<br />TV
<br />gr
<br />Accountant
<br />Public Accounting
<br />12
<br />16 FATH N -.NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />CD
<br />Z --1
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />. no. or nk.1 III yes. give war and dates of services)
<br />Nelda Rollstin
<br />19D. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />v
<br />rn
<br />rn
<br />O
<br />c. CEMETERY OR CREMATORY NAME
<br />- Lac- r -L,�. � -`°i,
<br />®Burial � Removal
<br />M 30 2001
<br />a ,
<br />Grand Island Cemetery
<br />22a. FUNERAL H (JIME NAME ,
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑D ° "al
<br />°° I Grand Island, NE
<br />22b FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND Icll Interval between onset and dean
<br />PART qT
<br />I fal Natural causes li unknown
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(b)
<br />v7
<br />Icl
<br />-n
<br />c::)
<br />y
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />11
<br />,Ages 10 -541 Yes No
<br />Ves No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pentlmg
<br />26e. INJURY AT WORK
<br />c� tom\
<br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />Investigation
<br />t--'
<br />o ice bmlding. etc. (Specify/
<br />Homicide
<br />rT1
<br />27a DATE OF DEATH (Mo.. Day YO
<br />D M
<br />28a. DATE SIGNED (Mo.. Day Yr)
<br />6C9
<br />D M iT
<br />r Us
<br /><
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<br />TV
<br />28cc. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />2Bd. PRONOUNCED DEAD (Hour)
<br />_._� M
<br />a
<br />¢_�
<br />(DD
<br />M
<br />D
<br />°
<br />a
<br />27d. To the best of my knowledge. death occurred at the time. date and place and due to the
<br />28e. On the basis of examination ardor investigation, in my opinion death occurred at
<br />d Io the slat
<br />causelsl stated.
<br />the time, date and place and causelsl
<br />cn
<br />F---a
<br />Cn
<br />ilZ
<br />31 HAS ORGAN OR TISSUE DONATION CONSIDERED?
<br />30.D WAS C ENT GRANTED?
<br />YES NO UNKNOWN
<br />jBEEN
<br />YES 1 VI NO
<br />YES El NO -
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<br />v v
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL-.P
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAY".
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE AP y
<br />DEC 3 2001 200112 5 2 5
<br />LINCOLN, NEBRASKA HEALTH Al
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAIFW .
<br />VITAL STATISTICS
<br />i-VID TTT+Tr A TA n1P TIT? A 7L �
<br />SERVICES
<br />® f E WITH'
<br />3..WNICH /S
<br />W5,1 `� R
<br />_ 00M r
<br />�Py4iVCe`A1tiI±JPPURT
<br />01 06191
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX ':',
<br />3. DATE OF DEATH /Mont. Day. Veer/
<br />Warren Rex Rollstin
<br />Male
<br />May 24, 2001
<br />4, CITY AND STATE OF BIRTH (ll not in USA.. name country)
<br />-Last
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day Year;
<br />MOS. DAYS
<br />Sc.HOURS MINS.
<br />Jul 14 1915
<br />Trumbull, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />OF DEATH
<br />0
<br />78a
<br />518 -07 -3971
<br />OSPITAL Inpatient OTHER Nursing Home
<br />ER Outpatient Re9dence
<br />8b. FACILITY - Name (If not mshfutiod, give street and
<br />1716 North Park
<br />❑ DOA Other(Specdyi
<br />Bc CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />. COUNTY OF DEATH
<br />Grand T"sl:AtO t' `-` �. -_ .., _
<br />'So
<br />r.,- ®. No ❑
<br />Hall
<br />go. RESIDENCE -STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER (Including LO Cotlel
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1716 North Park 68803
<br />Yea ® No
<br />10. RACE - Ie.g.. White. Black. American Indian.
<br />t 1. ANCESTRY le g_ Italian. Mexican, German, etcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE Ill wile. give maiden name)
<br />fec.I ISPecifyl
<br />White
<br />(spec'N)
<br />American
<br />NEVER DIVORCED
<br />,
<br />Nelda Bliss Curtis
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION
<br />(Specify only highest g,.de competed)
<br />Elementary or Secondary (1121 College 11.4 or 5• I
<br />4
<br />of working life, even it rehreO
<br />Accountant
<br />Public Accounting
<br />12
<br />16 FATH N -.NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />James Rollstin
<br />Alta Jeffers
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />. no. or nk.1 III yes. give war and dates of services)
<br />Nelda Rollstin
<br />19D. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />716 North Park, Grand Island, NE'. 68803
<br />EMB MER SIGNATURE 8 LICENSE NO S
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY NAME
<br />- Lac- r -L,�. � -`°i,
<br />®Burial � Removal
<br />M 30 2001
<br />a ,
<br />Grand Island Cemetery
<br />22a. FUNERAL H (JIME NAME ,
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑D ° "al
<br />°° I Grand Island, NE
<br />22b FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND Icll Interval between onset and dean
<br />PART qT
<br />I fal Natural causes li unknown
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(b)
<br />Interval between onset and death
<br />DUE TO. OR AS A CONSEOUENCE OF
<br />I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but hot 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 />11
<br />,Ages 10 -541 Yes No
<br />Ves No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pentlmg
<br />26e. INJURY AT WORK
<br />261. PLACE OF, INJURY -At home. farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />Investigation
<br />yes No
<br />❑ ❑
<br />o ice bmlding. etc. (Specify/
<br />Homicide
<br />27a DATE OF DEATH (Mo.. Day YO
<br />28a. DATE SIGNED (Mo.. Day Yr)
<br />28b TIME OF DEATH
<br />D M iT
<br />r Us
<br /><
<br />27b. DATE SIGNED (MO.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28cc. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />2Bd. PRONOUNCED DEAD (Hour)
<br />_._� M
<br />a
<br />¢_�
<br />t'1 24, 2
<br />M
<br />S_
<br />o ,=
<br />°
<br />a
<br />27d. To the best of my knowledge. death occurred at the time. date and place and due to the
<br />28e. On the basis of examination ardor investigation, in my opinion death occurred at
<br />d Io the slat
<br />causelsl stated.
<br />the time, date and place and causelsl
<br />(Signature and Title ) ►
<br />oil
<br />Si nature and Title ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />31 HAS ORGAN OR TISSUE DONATION CONSIDERED?
<br />30.D WAS C ENT GRANTED?
<br />YES NO UNKNOWN
<br />jBEEN
<br />YES 1 VI NO
<br />YES El NO -
<br />y
<br />n
<br />DA
<br />rr.)
<br />
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