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200112884 Rev I s's' - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERvjcFS FINANCE AND SUPPORT VrrAL STAnsncS CRRTIFICATF. OF nRATH z W 0 W 0 W 0 W 0 WW G Q Z ri C1 1 DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3 Dar YNd Marcella Marie Kircher Female 7DATE 000 a CITY AND STATE Of BIRTH lanwkr I1 SA nema cMmnyl 58 AGE - Laat Birthday UNDER I YEAR UNDER 1 DAY 6 DATE OF BIRTH /MarN1 Dar v-1 Haigler, Nebraska " "' 73 5h July 22, 1926 Mos DAYS Sc HOURS' MINS 7 SOCIAL SECURITY NUMBER 6a PLACE OF DEATH —" • 507 -20 -9445 HOSPITAL C❑� InpaaAM OTHER ❑ Nwsrnq Flprne _. _.. ❑ ER OU ANeM ❑ Nesdence p 6b FAgLITY - Nama la nor rnshNlirar slrenl anAnumher gi St. Francis Medical Center ❑ DOA ❑ OtherjSrwIp 6c CITY TOWN OR LOCATION Of DEATH 8d. INSIDE CITY LIMITS Be COUNTY OF DEATH -- Grand Island Yes ® No ❑ I Hall 9a RESIDENCE - STATE 9b COUNTY TOWN OR LOCATION Od STREET AND NUMBER Iftk.* pZO C**I 9e INSIDE CITY 0-MIS Nebraska Hall FtTY. Grand Island 1831 E. Sunset 68801 Ye+ ® No ❑ It) RACE Ie g, Whee Black Ame ¢an IMliAn I I. ANCESTRY (e IT Italian. Menton. German, elel 12. U MARRIED ❑ WIDOWED 13 NAME OF SPOUSE Ar ehk prym ,*A namel etc I ISoetdyl White ISveuNl American I NEVER DIVORCED Roger A. Kircher 14a USUAL OCCUPATION IGrre kdMol Work done during mosl 1 kh KIND OF BUSINESS INDUSTRY 15 EDUCATION (SpecKy OMy MOMN pads canhpekedl d wnrkmg rile, even it refired/ Homemaker Domestic EMme MAry a Setonclary .121 co", 11 -4 nr 5 • I 12th Gra�e 13 FATHER -NAME FIRST MIDDLE LAST t7 _ MOTHER FIRST MIDDLE MAIDEN SURNAME ' Frank Yager Mary Agnes Vontz 18 WAS DECEASED EVER IN US ARMED FORCES? t9a. INFORMANT -NAME - IYeS nn w unk 1 II yea. give. War and dales M aervifeel No - - - - - -- I Ro er Kircher 19h INFORMANT MAILING AODRFSS (STREET OR R F O NO CITY OR TOWN. STATE.. ZIP) 831 t, Gan slan_d, Nebraska 68801 ?I SICiNAtURE A LK: fN 218 MF.1WX)OFIYSPO51TION . DATE 21c CEMETERY OR CREMATORY NAME _ ❑Burial ❑Removal une 9, 2000 Central NE. Cremation Sery 72a rUNERAL H;;t(on-Sondermann A CEMETERY OR CREMAIORY LOCATION CITY OR TOWN STATE [Gibbon, Livin F.H. ®Cre -,,- El --I,- Nebraska 77h FUNERAL HOME ADDRESS ISIgFET OR R F D NO CITY OR TOWN. STATE, ZIP) - -'- 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 PART ,MMEDIATF CAUSE (ENTER ONL'V ONE CAUSE PER LINE FOR 181. (b). AND Icl) 1 k1MvN bshreen easel aM n •an 1 1� x 1 IaDU ' � i E . OR AS A CONS UE E OF -- - I arval b alYrlM Arh,el AM kt bet .@" I ro) 1 ecru_ Ive- 1 / bh 1A DUE TO OR AS A CONSEOVENCE OF I atervAl,lallwee duel end n�arn — 1 /� le) �i'r s rt Yom Dt i2r_ PART OTHER SIGNIFICAT CONDITIONS dadebns coati ing to the death bul nol,t d PART j III IF FEMALE. WAS THERE A 24 AUTOPSY 25. AS CASE REFERRED 10 MF01CAL PREGNANCY IN THE PAST 3 MO NiHS7 , EXAMINER OR COO" ' (Agas 10 -54) Yea NO Vas No k Yes No 268 26b DATE OF INJURY (Mo. On YrI 26c. HOUR CIF INJURY 26d. DESCRIBE HOW INJURY OCCURRED AccdeM F] Undme rued M SuicMS Farthing T6s INJURY AT WORK pF 5A CE 28T olfce Eu%IN 1911% hcv.larm. abeel taclory nq� M SPacal'I 269. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE Homicide In Iigatmn Yes ❑ No ❑ 27a DATE OF DEATH /Mn. Day Yr1 ` _ 268 DATE SIGNED /MO. Dav Yr I 26b TIME OF DEATH M 27b. DATE SIGNED (AAl DAY Yrl TIME OF DEATH 26c. PRONOUNCED DEAD /Ab Day. Yr1 20d. PRONOUNCED DEAD Mtxnr [21c w a M R M 77d To the best d my knowledge cwrsd al the amt, data and Mare And due to ale 208 On the basis d exanonid o arid d Inveshgahon, w my opmor, death occwred 0 -- .° tAlnelal +MMd >~ MWI Hml1, dste arhe pets A/M due b ela esusalal flalsd 9 s and Tab nature and Tft 79 DID TOBACCO USE CONTRIBUTE THE DEATH' 30a HAS ORGAN OR TISSUE' DONATION BEEN CONSIDERED' SOb WAS CONSENT GRANTED' x KYES ❑ NO ❑ UNKNOWN YES ❑ NO El YES Er YES X 31 #"t AND �QQRF.SS OF CERTIFIER IPHVSK;IAN, CORONER B PHYSICIAN OR COUNTY ATTORNEY( lfypp I [�sIS63 32a REGISTRAR 32b DATE FILED BY REGISTRAR (Mb.Day. Yrl FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV ............ ............... NSC.................................................................................................................................................................................................................... ............................... Census Tract No. Work.......................................................................................................................................................................................................................................................... ............................... UC ........ ... . ... ... . . . .................. ... ... . . . . ......... .... ... ........................... . ... .. ...... . ...... .. . . . . . .. . . .. ... . ... ... .... .... . . . . .... ... .. . ... . . . . . .. . .. . . . . ... ......... ... . ... .. . . ..... .... ... . ... .. . . . . . .. . ...... ......... ... . .. . . . .. . . Reject..................................................................................... 11.,,.,..........❑............... ................,.............. pop-, ' r , i� A; pl�'�aD �� YiMM6% neYtlM ' `ed �dli� �i i�Jebraska Signed in my presence tnis�.3� —day of Notary Public M W Lot Five (5), Block Three (3), Pleasant View seventh Subdivision in the City of Grand Island, Hall County, Nebraska.