|
Rev. 1�94 ` STATE OF NEBFiASKA—DEPARTMENT OF HEALTH �� �O�� ��
<br /> BUREAU OF VITAL STATISTICS
<br /> CERTIFICATE OF DEATH
<br /> � --
<br /> 1.DF.CEDENT-NAME FIR51 MIDDLE IAST 2 SEX 3.DATE OF DEA7H (MOnM Day Yead
<br /> LaVern NMN Crabtree Male September 27, 1997
<br /> --__ — --- _
<br /> � ri��,nNDS1niFO�P�ni�� innnlmUS4 nnmecnunln�' Sa n�F�LasIA���haav �UNDE���EAi7 UNDERIDAV 8 DATEOFBIFTH /M1MnM.On� �ead
<br /> ... __'_.____
<br /> ,v,�, no�. � on�s F�r+ouas MiNS june 19, 1906
<br /> Petersburg, Nebraska 91 ' _._.
<br /> 7.SOC�AI SECURT�V NUMBER Ba.PI�CE OF DEATH
<br /> .
<br /> 506-09-7176 HOSPI7AL � InOAlient OTHER � NwsmgHOme
<br /> Bb.FAGIITV-Name /nno�,nsr�lulion.g;ve sheer arW number) ._... ...—�- � ER OulPetient ---� � Fesidence
<br /> .
<br /> St. Franeis Medical Center ❑ ooA ❑ aha.�s�`-�" ___
<br /> 8t CiTY 70WN O�i lOCA710N OF DEATH Bd �NSIDE CITV UMITS 9e COl1ATV pF pEATH
<br /> Grand Island �B6 � "� ❑ Hall
<br /> 9a RESIDENCE-S7ATE 9b COUN7V 9c.CI1V.TOWN OR LOCAtiON 9d.STREET AND NUMBER pnUUdingZiO Codel 9e INS�OE CITV UMITS
<br /> � Nebraska Hall Grand Island 1905 W. Colle e 68803 VB3 Xn "�❑
<br /> 10 RACE�le.q.While.B�atk Ame�ican Indian. 11.ANCESTRV(e.g.Italian.Meei[art Germen.elcl 12.�MARRIED ❑WIDOWED 13 NAME OF SPOUSE 0�wAe grve meMen nnme/
<br /> eiclisoecMl �S��ry� American MEVea oivOaceo Thresia Thelander
<br /> � White ---
<br /> � t�a.USUAIOCCUPATION lG�vekirrddwo�kdonetlurirrgmosi �ab KINDOFBUSMESSINDUSTAV 15,EDUCATION �Speciyonyniqhergradecanple�eel . __
<br /> p o7wvrkmglAe.ev 7�enredl EkmenlaryaSecorMarylO-121 Col�e9P�t-no�5�
<br /> � Owner�Operator Restaurant 8th Grade ___
<br /> �
<br /> C 16.iA7NER-NAME fIR51 MIDDLE LAST �7 MOTHER FIRS7 MIDDLE MAIDEN SURNAME
<br /> � ; Zephaniak NMN Crabtree Rose Nt� Orr.derff _
<br /> O 18.WAS DECEASE�EVERIN U.5 AAMED FOACES� 19a.MiOFMANT-NAME .
<br /> I�'es.1w.o�u�k) Iu yee.g��e w�r antl dnies ol eervicee)
<br /> c No -------- Thresia Crabtree
<br /> � 19b INFOHMANT MNL�NG ADDRESS ISTREET OR R F D NO..CITV OR TOwN.STATE.ZIPI ,
<br /> � 19 College, Grand Island, Ne. 68803 ___
<br /> � 20 EM A -S�CNATURF.F CE 21a METHODOFDISPOSRION 21b.D�TE 21c CEMETERVORCPEMATOA�-NAME
<br /> U
<br /> Z d � y �y �a�,;s, ❑Remo�a, Sept. 30, 1997 Grand Island City Cemetery
<br /> w E A FUNEAAL E�NAME 2�d.CEMETERV OR CREMAIORV LOCATION C���OA TOWN STAiE
<br /> � �
<br /> w . ❑aeme�� ❑o�^a°°^ Grand Island Cit Cemeter
<br /> J � Liv gston-Sondermann F.H. y y
<br /> W j, 226.FUNERAI HOME AODRE55 (STREET OR R.FD.NO.CITV OR TOWN.S1ATE.ZIP)
<br /> � L
<br /> LL a 601 N. Webb Road, Grand Island, Ne. 68803-4050
<br /> � � 23. IMMEDIA7E CAUSE (ENTER ONLV ONE CAUSE PEA LINE FOR lal.Ib�,ANO�cq � �Merval Getween onset a�A c�eain
<br /> I
<br /> W d PART
<br /> � 48 hours
<br /> � _ ' ,e, Acute myocardial infarction �-�'" _
<br /> a O DUE TO.OR AS A CONSEOUENCE OF � Inlerval balween onset Tnn neam
<br /> Z LL �
<br /> i
<br /> t7 Ibl �
<br /> � DUE TO.OH AS A CONSEOUENCE OF: i Intervnl batwean Onse�a�e Aeaih
<br /> I
<br /> I
<br /> ��� I
<br /> OTHEP S�GNIFICANT COND�TiONS-Ca+Gi�lons contriMfirg lo Ihe death bul nol�elaleA PART III IF FEMALE.WAS iHERE A 2a AUiOPSV 25.WAS CASE REfERRED t0 MEDICAI.
<br /> PARt PREGNANCV W 7HE PASi 3 MONTHS9 EXAMINER OR COAONF��
<br /> �� Chronic ulmonaYt� fibrosis
<br /> p �j �Ages�0-Sa� Ves No Yes No Ves No
<br /> �e 26b DATE OF INJURV /Mo..Oay.Yr� 26c HOUfi OF INJURV 26A.DESCRIPE NOW INJURV OCCURREO
<br /> � AcciAenl � Undeterm�rred M
<br /> � Su�citle � �enAinq 26e MJUFV AT WORK 26i P�.ACE QF I�NOJP RY-A�rt�.iarm.street.lactwy 26g LOCATION STREET OR R.F.D.NO. CITV OR TOWN S7AT E
<br /> o�ce buddi S n��/
<br /> � HomiciAe i��e5l�qabo� Ves� No� _
<br /> 27a OATE OF DEATH /Mn Dav Yr.) 28n DA1F SIGNED /MO.Ony.Yrl 28b i1ME OF OEAiH
<br /> . a� a' SEPTEMBE�27 1997 b�� ""-
<br /> �,57ts 27� DnTE SIGNED /Mo Dae Y�I 27c TIME OF DEATH . ` 2BC PRONOUNCED OEAD /Mo Day.YU 28d.PRONOUNCED OEAD /Howl
<br /> �� 7 • 41PM ����
<br /> � p 8 199� � ""
<br /> 8 � 2Be.pn�he besis d e�ammauon and a inves�iqa�ion,in my opinion Deaih occurred a�
<br /> 27d.To Me besi ol my i e. eabf .ur n�Ihe time, te and dace and due to Me �� n 1he lime.date and dace end due lo Iha ceuselsl statetl.
<br /> o �pauselsl stated. � ,. Nl� /j���l.� .
<br /> (Si nalure antl Ti � I ,W " / elure an0 TiHa
<br /> 7n Dln 7nPACCO USE CO I T6� TN tl . ' 30a HAS OaGAN OR 71SSUE DONAtION BEE ONSI�ERED� 30.b WAS CONSENT GRANTED�
<br /> �.. � vE5 � NO � UNKNOWN� ,... n vE5 � NO � VES N� _-----
<br /> �1 NAME AND DR S OF CEATIFIER�FNVSICIAN,C0�70NER S PHVSICIAN OR COUNTV ATTORNEYi �1�0�Pi�nll
<br /> WILLIAM J LAWTOIV M . D . 2 F 1 8Q�
<br /> 3ffi DATE FILED B�AEGISiRAF (Mo.Day V�J
<br /> 32a REGISTRAR
<br /> FOR VITAL STATISTICS USE ONLY
<br /> Place.......................A................................B................................C...............................D...............................E................................Part II.....................TMV ..........................
<br /> NSC..................................................................................................................................................................................................................................................Census Tract No.
<br /> Work........................................................................................................................................................................................................................................................................................
<br /> UC.........................................................................................................................................................................................................................................................
<br /> Reject. ..........................................................................:.............. .................................. ..........
<br /> .........................................................................................
<br /> �Pnn1eA wlt��oY InF on ncYC1eQ O�Db��
<br /> Lot 1 , �lock 2.7 , Gzlbert ' s Third Addition to tlhe City of
<br /> Grand Island, Hall County, �lebraska .
<br /> I �pr�:l�� �'_'ri ' �Z1�� i , ., s ,, �;nr! r; v;� � ,•� k� ' ,i i
<br /> r .� � � z u� ,�� cc ��t c,;�.� of ���e ;,r�oi;�u� ��,� . , . , .
<br /> State cf i���L�1��'�;a � �
<br /> �'�--`"3���`w� �''%..�:3,,..-rl.�..__ ��j�— �E�� r� � �� �'c•.". ��
<br /> ----S.�L._ ,
<br /> �� .. �. __ �,�r -� :;:?i'-Sr;�t++ u
<br /> Sigr,���� �n r��,- ;�,r�::,�� � "�:s ��L-- r, , , , � . � ��:.. ��.,.', t „f�y Lr� -et,��rr�s�s
<br /> � �,
<br /> --- �u _ __ 1� _ ,�,}��,� rt,r "r'��N
<br /> � � �
<br /> : �
<br /> , ,.
<br /> <:,i% — �
<br /> ,, ,�
<br /> — — ------- _� --
<br /> ::; .,,,
<br />
|