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WHEN TENS COPY CARDS T1E RAISED SEAL OF THE NEBRASKA HEALTH AND -HUMAN SERVICES
<br />SYSTEIK !! CERTIFIES T1E BELOW TO BE A TRUE COPY OF THE 0R1GWtMC0RD ON'f/49 WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S*1 #EdttON+F/ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/10/2004 200402388
<br />-_ - ass7�T�Nf`-staTE �s/sriaaH
<br />LINCOLN, NEBRASKA HEALIW > HUMAN SERVICES �YSTEAll
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND I#UMAMER FD6%RC>FANb StWMRT C r�
<br />CERTI IF CATE OF DEA �I = 0 4 0 2 6 J L
<br />1. DECEDENT - NAME FIRST MIDDLE UST
<br />2. SIX
<br />3. -DATE OF DEATH (Month. Day. Year/
<br />Loretta M. Farlee
<br />Female
<br />February 25, 2004
<br />4. CITY AND STATE OF BIRTH X not in USA. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />h
<br />Greeley Nebraska
<br />(Yns.l 5b.
<br />82
<br />MOS. DAYS
<br />'
<br />-n
<br />C
<br />June 09, 1921
<br />CA
<br />8a PLACE OF DEATH
<br />508 -16 -9162
<br />HOSPITAL: ❑ Inpatient OTHER: Nursing Home
<br />oC /
<br />8b. FACILITY - Name /Hrwf inshfuthow, give street and number)
<br />Edgewood Vista
<br />Z
<br />A
<br />=
<br />Be. COUNTY OF DEATH
<br />o
<br /><_W en
<br />Hall
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />go. STREET AND NUMBER tlnc /udingZip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />�
<br />Grand Island
<br />1918 W 1st. St., 68803
<br />Yes No
<br />10. RACE - (e.g., White. Black. American Indian,
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etcl
<br />12. © MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE ttf wife. give maiden name/
<br />etc.) (Sllecifyl
<br />White
<br />(Speciyl
<br />American
<br />NEVER DIVORCED
<br />Paul J. Farlee
<br />14a USUAL OCCUPATION (Give kkrdof work done during may
<br />OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade cOM~)
<br />d working life, even it re6raW
<br />Secretary
<br />74bKIND
<br />ol
<br />Elementary or Secondary (a 12) COOT If -4 or 5• I
<br />L
<br />18. FATHER -NAME FIRST MIDDLE UST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William (NMI) Slattery
<br />I Margaret (NMI) Schrum
<br />rn
<br />1ga INFORMANT -NAME
<br />(Yes. no. or unit.) I6 yes. give war and dates of services)
<br />No
<br />Paul J. Farlee
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP)
<br />1918 W Ist St., Grand Island, NE 68803
<br />26 EMBALMER - SIGNATURE 8 LICEN4,E N -
<br />i- A
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1254
<br />IN eme, ❑ Ramd,a,
<br />02/28/2004
<br />West Lawn Memorial Park
<br />22a FUNERAL - N E
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine neral Home
<br />❑ �^ ❑ odnaedn
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />3213 W North Front St Grand Island, NE, 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ,al. (b). AND (c)) Interval between Onset and death
<br />PART I
<br />1(a) CONGESTIVE HEART FAILURE
<br />DUE TO, OR AS A CONSEOUENCE OF I Iraery it between or".and death
<br />I
<br />(b) HYPERTENSION
<br />DUE TO. OR AS A CONSEOUENCE OF' Interval between onset and death
<br />I
<br />I
<br />(q
<br />= M
<br />G
<br />AUTOPSY
<br />1,25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />IXAMINER OR CORONER?
<br />II ALZHEIMER'S DISEAS (Ages
<br />10-541 vas 0 No
<br />Yea No
<br />26a.
<br />26b. DATE OF INJURY tMo.. Day. Yr.)
<br />26c. I4OUR OF INJURY
<br />26d: DESCRIBE HOW INJJRY OCCURRED
<br />Accident r-] Undetermined
<br />0
<br />3
<br />�v
<br />26e. INJURY AT WORK
<br />26f. PLACE QF INJURY -, Home, farm, street. factory
<br />bUi etc. $peCJtYi
<br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />' ❑❑
<br />Ves No ❑
<br />Office
<br />27a. DATE OF DEATH tMa. Day. Yr.)
<br />28a. DATE SIGNED tMo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />February 25, 2004
<br />0
<br />M
<br />27b. DATE SIGNED (Md. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day. Yr)
<br />28d. PRONOUNCED DEAD /Hour)
<br />"�
<br />March
<br />7.00 A.M. M
<br />M
<br />s
<br />CAD
<br />v
<br />28e. On the basis of examnation antl'a investigation, in my opinion death occurred at
<br />camels) stated. / _
<br />v 6
<br />the time, date and place and due to the causels) stated.
<br />(Signature and Tale) ► (f y
<br />-J
<br />29. DID TOBACCO USE CONTRIIIU X TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WHEN TENS COPY CARDS T1E RAISED SEAL OF THE NEBRASKA HEALTH AND -HUMAN SERVICES
<br />SYSTEIK !! CERTIFIES T1E BELOW TO BE A TRUE COPY OF THE 0R1GWtMC0RD ON'f/49 WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S*1 #EdttON+F/ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/10/2004 200402388
<br />-_ - ass7�T�Nf`-staTE �s/sriaaH
<br />LINCOLN, NEBRASKA HEALIW > HUMAN SERVICES �YSTEAll
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND I#UMAMER FD6%RC>FANb StWMRT C r�
<br />CERTI IF CATE OF DEA �I = 0 4 0 2 6 J L
<br />1. DECEDENT - NAME FIRST MIDDLE UST
<br />2. SIX
<br />3. -DATE OF DEATH (Month. Day. Year/
<br />Loretta M. Farlee
<br />Female
<br />February 25, 2004
<br />4. CITY AND STATE OF BIRTH X not in USA. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH Imonf,4. Day. Pearl
<br />Greeley Nebraska
<br />(Yns.l 5b.
<br />82
<br />MOS. DAYS
<br />'
<br />Sc. HOURS' MINS.
<br />June 09, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />508 -16 -9162
<br />HOSPITAL: ❑ Inpatient OTHER: Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /Hrwf inshfuthow, give street and number)
<br />Edgewood Vista
<br />❑ DOA ❑ OtifertspecdY)
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8d, INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />yea X No ❑
<br />Hall
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />go. STREET AND NUMBER tlnc /udingZip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1918 W 1st. St., 68803
<br />Yes No
<br />10. RACE - (e.g., White. Black. American Indian,
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etcl
<br />12. © MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE ttf wife. give maiden name/
<br />etc.) (Sllecifyl
<br />White
<br />(Speciyl
<br />American
<br />NEVER DIVORCED
<br />Paul J. Farlee
<br />14a USUAL OCCUPATION (Give kkrdof work done during may
<br />OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade cOM~)
<br />d working life, even it re6raW
<br />Secretary
<br />74bKIND
<br />ol
<br />Elementary or Secondary (a 12) COOT If -4 or 5• I
<br />L
<br />18. FATHER -NAME FIRST MIDDLE UST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William (NMI) Slattery
<br />I Margaret (NMI) Schrum
<br />t8. WAS DECEASED EVER IN U.S. ARMED FORCES? -
<br />1ga INFORMANT -NAME
<br />(Yes. no. or unit.) I6 yes. give war and dates of services)
<br />No
<br />Paul J. Farlee
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP)
<br />1918 W Ist St., Grand Island, NE 68803
<br />26 EMBALMER - SIGNATURE 8 LICEN4,E N -
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1254
<br />IN eme, ❑ Ramd,a,
<br />02/28/2004
<br />West Lawn Memorial Park
<br />22a FUNERAL - N E
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine neral Home
<br />❑ �^ ❑ odnaedn
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />3213 W North Front St Grand Island, NE, 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ,al. (b). AND (c)) Interval between Onset and death
<br />PART I
<br />1(a) CONGESTIVE HEART FAILURE
<br />DUE TO, OR AS A CONSEOUENCE OF I Iraery it between or".and death
<br />I
<br />(b) HYPERTENSION
<br />DUE TO. OR AS A CONSEOUENCE OF' Interval between onset and death
<br />I
<br />I
<br />(q
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />1,25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />IXAMINER OR CORONER?
<br />II ALZHEIMER'S DISEAS (Ages
<br />10-541 vas 0 No
<br />vas p Nb
<br />Yea No
<br />26a.
<br />26b. DATE OF INJURY tMo.. Day. Yr.)
<br />26c. I4OUR OF INJURY
<br />26d: DESCRIBE HOW INJJRY OCCURRED
<br />Accident r-] Undetermined
<br />M
<br />❑ Suicide 7 Pending -
<br />26e. INJURY AT WORK
<br />26f. PLACE QF INJURY -, Home, farm, street. factory
<br />bUi etc. $peCJtYi
<br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />' ❑❑
<br />Ves No ❑
<br />Office
<br />27a. DATE OF DEATH tMa. Day. Yr.)
<br />28a. DATE SIGNED tMo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />February 25, 2004
<br />0
<br />M
<br />27b. DATE SIGNED (Md. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day. Yr)
<br />28d. PRONOUNCED DEAD /Hour)
<br />"�
<br />March
<br />7.00 A.M. M
<br />M
<br />s
<br />27d To the best W my knowledge. a at 1M rime, d a place and due ttre
<br />28e. On the basis of examnation antl'a investigation, in my opinion death occurred at
<br />camels) stated. / _
<br />v 6
<br />the time, date and place and due to the causels) stated.
<br />(Signature and Tale) ► (f y
<br />Signature and TIM) ►
<br />29. DID TOBACCO USE CONTRIIIU X TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />130.a
<br />❑ YES NO ❑ UNKNOWN ❑ YES Lk l_
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Prim)
<br />W. J. Lawton M.D. 2444 West Faidlew Ave. Grand Island NE 68803
<br />321L REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.J
<br />MAR 9 2004
<br />
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