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s <br />n � <br />= N <br />n CA <br />7C = <br />200402099 <br />A <br />=c <br />m <br />'rl <br />RT A <br />9 <br />C� <br />'D <br />W <br />GJ <br />CD <br />Co <br />O -4 <br />C � <br />z rn <br />CD T, <br />= rn <br />p. Fp <br />r � <br />r ry <br />cn <br />D <br />00 <br />4C► <br />WHEN THIS COPY CADS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, ffWM WS THE BELOW TO BE A TMt1E COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HIMiAN SERWCES SYSTEM, VITAL STATISTM3 f rTift WCH IS <br />THE LEGAL DEPOSITORY FOR WITAL RECORDS. <br />DATE OF ISSUANCE Lot 5, Block 3 in Kay iN <br />Dee Subdivision in the AR __ <br />SEP 17 2003 y =��R <br />Cit of Grand Island, ASSBSTAS�T#REGUS�'R�_iR <br />LINCOLN, NEBRASKA Hall County, HEALTH AND /�Y/&AA4%#&bSXSF_M <br />Nebraska -_ <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN N_RY�S. M- 164 Dif3 §UPYORT <br />�J OO LL 0 Z O 9 VITAL STATISTICS e1s C <br />I� T CERTTFTrATFnFT)FATTJ - ET� 06238 <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Monts. Day. Year) <br />Betty Jane Maggiore <br />Female <br />June 1, 2003 <br />4, CITY AND STATE OF BIRTH (If not h US.A., name country) <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Monts. Day. Year) <br />Canton, Ohio <br />(Yrs.l 84 Sb. <br />MOS. DAYS <br />5c. HOURS' MIN-S <br />L7 <br />May ry n 1919 <br />7. SOCIAL SECURTIY NUMBER <br />Ba. PLACE OF DEATH <br />505 -94 -1201 <br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />Bb. FACILITY - Name /ara inslitbfion, give street and number) <br />St. Francis Medical Center <br />❑ DOA ❑ Other(Specdv) <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® Nd ❑ <br />I Hall <br />Be. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Lp Codel <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2020 Del Mar Ave. 68801 <br />Yes k]_ No <br />10. RACE -(e.g., White. Black. American Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, etc) <br />12. MARRIED j� WIDOWED <br />13. NAME OF SPOUSE Of wife. give maiden name) <br />etc.! ISoecdy) <br />White <br />ISpectNl <br />American <br />NEVER DIVORCED <br />MAR <br />Dr. Carl H. Ma fore <br />14a. USUAL OCCUPATION (Give kind of work done during most 14b. <br />oworking h1e, even if refired) <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary 10 -12) College IT -4 or 5 -I <br />Registered Nurse <br />Hospital <br />4 Years <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Wilbur Kiehl <br />Harriet Pearson <br />18. WAS DECEASED <br />EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes no. or unk.) <br />pf yes. give war and dates of services) <br />No <br />I -- - - - - -- <br />Dr. Carl H. Maggiore <br />191b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) <br />020 Del Mar Ave., Grand Island, Nebraska 68801 <br />ALMER - SIGNATUUURRRE 8 LICENSE <br />// +_3 <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />ENO. <br />' `, `- "`^�l.R/� <br />a] Burial ❑ Removal <br />June 4, 2003 <br />Grand Island City Cemeter <br />22a. FUNERAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston - Sondermann F.H. <br />❑Cremabon 1:1 Donation <br />Grand Island Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE <br />PART O <br />(�C %AUSE D J� /y (//1 A /'(� /(EENTE�R ONLY ONE CAUSE PER LINE FOR lal. (b), AND (c)) Interval between onset and death <br />b L'(.� <br />L,Q l KJC. 'P Wl V" ` <br />(al I CCCXJCX <br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death <br />(b) <br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death <br />I <br />lot <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />(Ages <br />TO -54) Yes No <br />Ves No <br />Yes No <br />26a. <br />26b. DATE OF INJURY /MO.. Day. Yr) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />261. PLACE OF INJURY - ,l home, farm, street. factory <br />office w ding. etc. /Specify) <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes Na ❑ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day. Vrl <br />281b . TIME OF DEATH <br />M <br />o <br />_> It <br />27b. DATE SIGNED (Mo.,�Daay Yr) <br />T27C. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day. Yr) <br />28tl. PRONOUNCED DEAD /Hour) <br />'gJ <br />I c� -1 -v3 <br />3'�� A M <br />¢ i o <br />M <br />$' i <br />27tl. 7o the best of my kni rred at the time, date and place and due to Me <br />28e. On the basis of examination and 'or investigation, in my opinion death occurred at <br />o ° <br />ause(sl stated. <br />Xth <br />° = <br />the time, date and place and due to the cause(sl stated. <br />(Si nature and Titlel ► <br />(Signature and Title) ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b <br />WAS CONSENT GRANTED? <br />YES NO UNKNOWN <br />❑ YES NO <br />❑ YES %� NO <br />�/ <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEVI /Type or Print! <br />132a. REGISTRAR \ <br />321b . DATE FILED BY REGISTRAR /MO. Day. Yr.) <br />SUN - 5 2003 <br />C= <br />N <br />O <br />0 <br />-C <br />O <br />N <br />CD <br />co <br />CD <br />Lot Five (5), in Block Three (3), Kay Dee Subdivision, Grand Island,Hall County, Nebraska <br />f'17 <br />7 <br />frF <br />Z <br />c <br />