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<br /> The easterly 196.0 feet of the southerly 160.0 feet of the northerly 489.16 feet of �
<br /> Lot 12 of the County Subdivision of part of the Southeast Quarter of Section 19, Town- �
<br /> ship 10 North, Range 11 West of the 6th P.M. , Hall County, Nebraska, Subject to that
<br /> �a.r.t r.h�reof f�r. caunty ro� i i�r.t-of-w�y.
<br /> _���' _ �9 �:0� 582
<br /> WFEN 1FRS�YGId�ES 11f RAMED aE/IL OF riE IIEM�� iERNCE8
<br /> SY�TEII�IT CERTFE3IFE BFlOW TO QE A TRUE C0�1"
<br /> THE NEBRASKA HEALTH AND HUMAN SERVM.�S S�'S - _���lf�CTJON.M�'�ICH/S
<br /> THE LEIiAL DEPOSITORYFOR VITAL RECORDS "" ' �� ,�
<br /> ����;:�,, - �t j�DLt+
<br /> DATE OF 13SUANCE : "'� � � ���� ��
<br /> _`- "� �Y S.COOPER
<br /> UNC � NEBRASKA _s �-��� _?�3 �M
<br /> �
<br /> - `=_� _,. .=
<br /> } STATE OF NEBRASKA-DEPARTMENT OF HE r �� E$FINANCE AND SUPPORT
<br /> VITAL`S
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT-NAME FIflST . MIDDLE LAST 2.SEX 3.DATE Of DEATM /Month,Osy,Yesr/
<br /> Ross Erwin Waite Male Februaz 1 1999
<br /> 4.CITV AND$TATE OF BIRTH-lJ/not in U.S.A.,nsme rnuntryl 5a.AGE-Lest Bir[hday UNDER 1 VEAR UNDEN 1 DAY 8.OATE OF BIflTH lMonrh,Osy,Yasi/
<br /> (Vn.l 6b.MOS. OAVS 6c.HOU15 MINS.
<br /> Ha i South Dakota 73 � ' March�31925
<br /> 7.SOCUIL SECURITY NUMBEH 8�.PLACE OF DEATH
<br /> SVY'20�722 ��TAL: �InpsqsM OTHER: �Nurdnp Hame
<br /> 8b.FAqLITV-Name lN iwrWNtut/on,pive sbeet�MnwMsl �ER Outpatisn[ �flddtncs
<br /> w
<br /> St. Francis Medical Center ��A ��««���Y� --
<br /> 8c.CITV,TO WN Ofl LOCATION OF DEATH Bd.INSIDE CITY LIMITS Be.COUNTY OF DEATM
<br /> Grand Island Y�. � No ❑ Hall
<br /> Be.RESIDENCE-STATE 9b.COUNTY 8e.CITY.TOWN Ofl LOCATION 8d.STNEET AND NUINBER lMrJudJnp Zip Cade/ ee.INSIDE CITY LIMITS
<br /> Nebraska . Hall Wood River 1002 Elm St. 68883 Y�, � No ❑
<br /> 70.RACE-(e.p.,White,Black,Ameriean IMien, 11.ANCESTflYN.p..M�Yn,N�de�n,O�rmen,ne.) �O 12.❑MARRIED �WIDO WED 13.NAME OF SPOUSE lIl wile,g/ve meiden name/
<br /> �"(S�'Y' ,��' NEVFR DIVORCED
<br /> White Germ /Iri h ❑
<br /> 14e.U3UAL OCCUPATION•/C/ve IrMO ol wwk done CwMymoa(,�/\ 14D.KHJD OF BUSWESS INDUSiRY O)� 16.EDUCATION SPECFY ONIV H16MEST ORADE COMPIETEDI __
<br /> IJ�J` e.v`� EMm.nnn«s.enndrv w-�z-��-� c
<br /> o/working Q/e,sven//rMNed/ oNp�(i-C a 5�1
<br /> General C ntractor Cement 12 '
<br /> i 16.FATHER-NAME FIflST MIODLE Lp,ST 17.MOTHER FIRST MtDDLE MAIC�FN SUIiNAMf
<br /> CI de Waite Clara Jensen
<br /> 18.WAS OECEASED E`!ER IN U.S.ARMED FONLES7 18a.INFONMANT-NAME
<br /> (Yet.1q nr unk I IM Yw.pw wu snd deln�f nrvkal
<br /> YES WW II 11/17l44 to 04/OS/46_J Terry Waite
<br /> 19b.WFOFMANT MAILING ADORESS ISTREET Ofl R.F.D.NO.,CITV OR TOWN,STATE,ZI%
<br /> 12900 39th Rd. Elm Creek NE. 68836
<br /> 20.EMBA -SIGNATURE 8 LIC[NS /�y�� 27a.METHOD OF DISPOSITION 21D.OATE 21c.CEMETERV nH CNEMA�ORV-NAME
<br /> � �
<br /> __ ���,� �Rarovd 02/OS/1999 Wood River Cemetery
<br /> 22a.F NAL HOMF .AME 21tl.CEMETEPY OR CNEMATOHV LOCATION CITV OH 70WN STA7E
<br /> A fel Funeral Home ❑G����^U��^�� Wood River Nebraska
<br /> 22b.FUNEIiAL HOME ADDHESS ISTREET ON N.F.D.NO.,CITY OR TO WN,STATE,ZI%
<br /> Wood River NE. 68883 •
<br /> 23. IMMEDIATE CAUSE IENTER ONLV ONE CAUSE PEfl LINE FOR IU.( .�dD(c1) � Intaval batween onse[ana 0eatn
<br /> PAflT I
<br /> � ��^ O
<br /> � /<'Q I /CS�C'•C�`/� �--�..S�or_=-_
<br /> 7��c r,OR AS A CCNSEDUENCE OF � Interval between o q�e A e atn
<br /> _ � , � - . ... .
<br /> ..1...' _ - '' '. . ./ � .
<br /> "''_: ' _-�--�'-- � ' /� �� /�
<br /> „ ... b � �y9�C�0//J ��^ L✓�``� LT �Q/W! /C'✓t�' �
<br /> C v
<br /> WE TO OH AS A CON3EQUENCE OF ��� yr � intKVN beeweei�onsec ena aea�n
<br /> � / / .,// I .
<br /> cl ��T �� � J�/CS/O� ?'� Y/7d��/ � p
<br /> OiHEfl SIGNIFICANT CONOITIONS-ConA�iar eonnWtinp�o tM dwt�Wt not r tM PAflT III IF FEMALE WAS THERE A 24.AUTOPSY 5.WAS CASE REFEHRED TO MEDICAL
<br /> PAH"I , PREG�IJANCV IN THE PAST 3 MONTHS7 EXAMINER OR CORONEH7
<br /> II �zr
<br /> 7 Q C �--nlrl (Ape 10-5�1 Yn No Vn No Vn No
<br /> 28a. 286.DATE OF MJURV IMo,Llsy,Vi.! 28c.HOUfl OF INJURY 28d.DESCflIBE HOW INJUHV OCCUHHEO
<br /> ❑Aeeitlem LJ UiMeterminN M
<br /> �g�� �pe�„u 28a.INJURV AT WORK 28t.PLACE OF INJUNV-A�honr,lerm,nrM�,lee�«y 28g.LOCATION STREET OH fl.F.D.NO. CITV OR 70WN SiATE
<br /> j� I 1 ol/iec DuilAing.etc.�l.;pecily;
<br /> LJ NmiciM Inv�etip�tion Ves LJ No�
<br /> 27a.DATE OF DEATH IMO,OaY.y��� 28a.DATE SIGNED/MO,DeY.Y��) 28b.TIME OF DEATH
<br /> Februar 1 1999 ��� M
<br /> ay`- 27b.DATE SIGNED lMo,D�y,Yi.1 27c.71ME OF DEA7H �G Y 28c.PHONOUNCED OEAD/Mo,Osy,Y.l 2Bd.PfiONOUNCED DEAD lHou�/
<br /> U�O y
<br /> a < �
<br /> Februa 3, 1999 11:10 PM M ���g M
<br /> 8'� 47d. To[he best ol mV��ed9�.dfN h occurred at tM ' e.dMe ace and due[o the '�'g s 28a. On tM ba�i�ol examination and/a mvenigation,in myopinion dea�h occurm0 at
<br /> causesb)auted. / the tlme adate and plece and tlue m the causelsl rw[ed.
<br /> I�qroture an0 Title � (S�O�tu�e and Titlel ►
<br /> 29.DID TOBACCO USE CONTRI TE TO THE DEATHT 30a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDEHEDi 30A.WAS CONSENT GflANTEDI L
<br /> n(� YES ❑ NO ❑ UNKNO WN ❑ VES � NO O VE3 '7[� NO
<br /> f�' �.T_ Y"`
<br /> 31.NAME AND AUONESS OG CEflTIF1ER IPMYSICUW,COflONER'S PHYSICtAN OH COUNTY ATTOfWEY1 /Typ�w RMtI
<br /> Jane A. McDonald M.D. ha S d Island NE 6�803
<br /> 32a.NECi1STRAR r i1 w�� . _ 32b.DATE FIIED BY NEG16TflAfl /Mo.Ory.Y J .
<br />
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