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<br />WHEN IM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALM AND=HUMAN SERVICES
<br />SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORB 4M Ffi.EiWTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS=4$U41il3Ar1k4IlCH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = -
<br />DATE OF ISSUANCE
<br />ANLEYS. CWMR
<br />12/9/2003 200402665 �fSS TABFMWWGIS R
<br />LINCOLN, NEBRASKA HEALTHAN6 ffUWAF SERVICE] $V11XM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE1i"C&fIN WC E A SUPPORT ^'
<br />VITAL STATISTICS 0 3 13765
<br />CERTIFICATE OF D TH EA -=
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monty. Day. Year)
<br />Mary Lou NMN Roe
<br />Female
<br />November 26, 2003
<br />4. CITY AND STATE OF BIRTH 1ll not h U.S.A.. name courmyl
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH tMaMt. Day. Year)
<br />MOS. I DAYS
<br />Sc. HOURS' MINS.
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<br />n
<br />=
<br />' SOCIAL SECURTIV NUMBER
<br />�
<br />o
<br />Q
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name terrot inslum,, gve street and number/
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other /Spector
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />C=
<br />Nom.
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />91p. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlncluft Zip Codel
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />3
<br />z
<br />204 W. 9th 68801
<br />Yes x No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />n
<br />y
<br />13, NAME OF SPOUSE ttl wde. give maiden name)
<br />tltc.l (Sped
<br />Ohite
<br />(Specify)
<br />Swedish
<br />�
<br />M
<br />-� p
<br />14a. USUAL OCCUPATION /Give kMdol work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />0
<br />Domestic
<br />Elementary or Seconrar 10 -12) College 11 -4 or 5-1
<br />L1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Ray Gaylord
<br />1
<br />40
<br />O
<br />O
<br />'0
<br />No
<br />I
<br />Don Roe
<br />O
<br />204 W. 9th, Grand Island, NE. 68801
<br />CL�
<br />21 a. METHOD OF DISPOSITION
<br />S
<br />721cCEM,1 TER Y OR CREMATORY NAME
<br />Burial ❑Removal
<br />Dec. 29, 2003
<br />stlawn Memorial Park
<br />22s. FUNERAL HqAE -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑Dorton
<br />Grand Island, NE
<br />22b, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Mi. AND (c)) Interval between onset and death
<br />PART) S U/0-4 LAJ M I +C-
<br />DUE TO, OR AS A CONSEQUENCE OF - - I Interva onset and death
<br />I
<br />.(b) I
<br />- DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and tleath
<br />I
<br />(q I
<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 70 MEDICAL
<br />II Y[/ /� �[ PREGNANCY
<br />O
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />/ / /' �.�' // I (Ages
<br />10 -54) Yes No
<br />Yes N0 2�
<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 />to
<br />N
<br />;K
<br />Q7
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PLAe E OFINJURY /5home, (arm. street. factory
<br />dfificc bull 4.
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />3+
<br />C" CD
<br />27a. DATE OF DEATH /MO.. Day. Yr.)
<br />28a. DATE SIGNED JA46. Day. Yr.)
<br />281b TIME OF DEATH
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<br />27b. DATE SIGNED tMo.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD tHourl
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<br />27d. To the best of my knowiOge. death time, date and due to the
<br />28e. On the basis of examination and'a investigation, in my opinion death occurred at
<br />a
<br />causelsl stated.
<br />v b
<br />fire time, date and place and due to the cause(s) stated.
<br />(Signature and Title) ►
<br />(Signature and Tnlel
<br />29, DID TOBACCO USE CONTRIBUTE-TO THE DEATH?
<br />HAS AN OATISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />Ta
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES XNO
<br />31. NAME AND ADDRESS Of CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typeor Pdnt)
<br />David R. Colan M.D. 7291N. Custe , rand Island NE 68803
<br />32a. REGISTRAR �f
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />V
<br />DEC 8 2003
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<br />0U
<br />E-1 � . U
<br />M -N r-i
<br />43 r_1
<br />0 0 0 W
<br />1a-ri--3x
<br />WHEN IM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALM AND=HUMAN SERVICES
<br />SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORB 4M Ffi.EiWTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS=4$U41il3Ar1k4IlCH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = -
<br />DATE OF ISSUANCE
<br />ANLEYS. CWMR
<br />12/9/2003 200402665 �fSS TABFMWWGIS R
<br />LINCOLN, NEBRASKA HEALTHAN6 ffUWAF SERVICE] $V11XM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE1i"C&fIN WC E A SUPPORT ^'
<br />VITAL STATISTICS 0 3 13765
<br />CERTIFICATE OF D TH EA -=
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monty. Day. Year)
<br />Mary Lou NMN Roe
<br />Female
<br />November 26, 2003
<br />4. CITY AND STATE OF BIRTH 1ll not h U.S.A.. name courmyl
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH tMaMt. Day. Year)
<br />MOS. I DAYS
<br />Sc. HOURS' MINS.
<br />Kansas City, MO
<br />(Yrs.) 69 5b.
<br />November 3, 1934
<br />' SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />505 -34 -8131
<br />HoSP_ITAL ® Inpatlma OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name terrot inslum,, gve street and number/
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other /Spector
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yea [Z Nd ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />91p. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlncluft Zip Codel
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />204 W. 9th 68801
<br />Yes x No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, atc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE ttl wde. give maiden name)
<br />tltc.l (Sped
<br />Ohite
<br />(Specify)
<br />Swedish
<br />NEVER DIVORCED
<br />MARRIED
<br />1 Don Roe
<br />14a. USUAL OCCUPATION /Give kMdol work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even itrotiredl
<br />Homemaker
<br />Domestic
<br />Elementary or Seconrar 10 -12) College 11 -4 or 5-1
<br />L1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Ray Gaylord
<br />1
<br />Amy Vinberg
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT - NAME
<br />(Yes. no. a unk.) (8 yes. give war and dates of services)
<br />No
<br />I
<br />Don Roe
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN, STATE ZIP)
<br />204 W. 9th, Grand Island, NE. 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />W /32S
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />721cCEM,1 TER Y OR CREMATORY NAME
<br />Burial ❑Removal
<br />Dec. 29, 2003
<br />stlawn Memorial Park
<br />22s. FUNERAL HqAE -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑Dorton
<br />Grand Island, NE
<br />22b, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Mi. AND (c)) Interval between onset and death
<br />PART) S U/0-4 LAJ M I +C-
<br />DUE TO, OR AS A CONSEQUENCE OF - - I Interva onset and death
<br />I
<br />.(b) I
<br />- DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and tleath
<br />I
<br />(q I
<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 70 MEDICAL
<br />II Y[/ /� �[ PREGNANCY
<br />O
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />/ / /' �.�' // I (Ages
<br />10 -54) Yes No
<br />Yes N0 2�
<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 />26f. PLAe E OFINJURY /5home, (arm. street. factory
<br />dfificc bull 4.
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /MO.. Day. Yr.)
<br />28a. DATE SIGNED JA46. Day. Yr.)
<br />281b TIME OF DEATH
<br />M
<br />r
<br />ji
<br />< }
<br />27b. DATE SIGNED tMo.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD tHourl
<br />M
<br />�zi�
<br />M
<br />27d. To the best of my knowiOge. death time, date and due to the
<br />28e. On the basis of examination and'a investigation, in my opinion death occurred at
<br />causelsl stated.
<br />v b
<br />fire time, date and place and due to the cause(s) stated.
<br />(Signature and Title) ►
<br />(Signature and Tnlel
<br />29, DID TOBACCO USE CONTRIBUTE-TO THE DEATH?
<br />HAS AN OATISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />Ta
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES XNO
<br />31. NAME AND ADDRESS Of CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typeor Pdnt)
<br />David R. Colan M.D. 7291N. Custe , rand Island NE 68803
<br />32a. REGISTRAR �f
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />V
<br />DEC 8 2003
<br />11
<br />
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