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D <br /> �J -- � <br /> � �N N <br /> C/� <br /> WF�N TF�S COPY CARlZ�3 TF�RA/SED SEAL OF THE NEBRA3KA HEALTH AND HUMAN.�EtNCES <br /> SYSTEII�IT CERTiF�S Ti�BELOW TO BE A TRUE COPY OF THE ORK3INAL REC013 �TH <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATI$T�GS_ ���I�=;=: <br /> THE LEQAL DEPOSITORY FOR VITAL RECORDS . -"" '- -�- -_ <br /> DATE OF/3SUANCE Q � ' �" �'��tl`' - �^_ <br /> Jt�N 171999 `�-���C►84'72 � � ���= -_ <br /> ASS/STA�iF��1�e .,^ R� _ <br /> UNCOLN,NEBRASKA HEALTMAND H ' ='' <br /> STATE OF NEBRASKA-DEPARTMENf OF f�ALTfi AND H[JMAN SERVI�ES Rd�= <br /> VCIAL STATfSTICS __ __.,__�- __. .A <br /> CERTIFICATE OF DEATH -=-_- =- = _- -_ <br /> 1.DECEDENT-NAME FIRST MIDDIE USi 2.SE% � � TM /MOnM.DaK YN�1 � <br /> Karen Evelyn Francisco Female June 10, 1999 <br /> 4.CITV AND STATE OF BIfiTH /tl nol n U SA..name counhyJ Sa.AGE-Uat BirMdaY INdDER 1 YEAR UNDER 1 DAV 6.DATE OF BIRTH /Mdrlh.Day V�ail <br /> Grand Island, Nebraska �'""' 82 � Mos o��s x.tauAS� M'"s. January 17, 191� <br /> 7.SpCIAL SECURTIV NUMBEA 8a.PUCE OF DEATH <br /> �' HOSPITAL: � 1npelieM OTHEfi�. � Nurs�ng Home <br /> . 508-14-1166 -- - <br /> BE.FACILITY-Name /a�a�nsnnnia�.givesneerananumeer) � EROu1p�Gem � R�siCence <br /> . <br /> St. Francis Skilled Care Center � ❑ °OA ❑ 01ne'�$QeC"' <br /> &.CITV.TOWN OR IOCATION OF DEATH 8E.INSIDE CITV LIMITS Be.CWNTY OF DEATH <br /> Grand Island � �„ � � ❑ Hall <br /> 9a.RES@ENCE-STATE 90.CQUNTV � 9c.CITV.TOWN OR LOCATION 9A.STIIEET AN NUMBER IMeN�diiq Zip Codsl �9s.INSIDE qTV LIMITS <br /> Nebraska Hall Grand Island 803 N. Kimball 68801 ��`� N�❑ <br /> 10.RACE-(e.g.,While.Black.Amencan kWian. 11.ANCESTRV le g_haliin.Mezitan.Germen,akl � 12.❑MARflIEO ❑WIDOWED 13.NAME OP SPOUSE IM wile.givs miiCen n/ms/ <br /> B",�5�`�", White �S�`anish/American NEVER DNORCED NA <br /> 11a.USUAL OCCUPATION /Grve kmd d ra�k OaM du�'ug masl l ID.KIND Of BUS�NESS INDUSTRY 15.EDUCATION �Spseily oMy MqMtl qrWa tompNMA� <br /> dNUrk lib.evenilreeireJi ENmen a ry10•t2) CdNqelt�aa5•� <br /> C�erk Retail Grocer Sales ��t�i Grade <br /> 18.PATHER-NAME FIRS7 MIDDIE UST 17.MOTMER FIRST MIDDLE MAIDEN SURNAME <br /> Chris NMN Rasmussen Mar Nl�i Sorenson <br /> 18.WAS DECEASED EVERIN U.S.ARMED FORCES? 19a.INPORMANT•NAME . <br /> �Ves rw.a unk.� IM yes.g�ve war an0 Cates d ssrvicesl <br /> i No ------- Bruce Francisco (Son) <br /> 190.INFORMANT MAILING ADDRESS u'TREET OR R.F.D.NO.,CIN OP TOWN.STATE.ZIP� � . � <br /> 242 S. Vine, Grand Island, Nebraska 68801 <br /> Ztl.EM � E -SIGNAT UC NO 21a.METHODOFWSPOSIT10N 21D.DATE ?tc CEMETERVORCfiEMATORV�NAME <br /> A � � '�-���1� ����� [�e�,+� ❑��a. June 14, 1999 Grand Island Cit Cemeter <br /> 22a.PUNERAL FIOME ME 210.CEMETERY OR CREMATORY LOCATION CITV OR TOWN STATE <br /> ' Livingston-Sondermann F.H. ❑G•'"'°°" �°oi"'"' Grand Island, Nebraska <br /> 22G.FUNERAL FIOME ADDRESS ISTREET OR ii.F.D.NO..CITY OR TOWN.STATE.ZIP) <br /> 601 N. Webb Road, Grand Island, Nebraska 68803-4050 <br /> 23.PART IMMED�AT USE , � IENTER ONIV ONE CAUSE PEA LI(E F a ial.IbL AND(cl) i Intarvai beiween onnet and aeam <br /> I <br /> x � ,a� q. o � � w <br /> � DUE TO,OR AS A C NSEOUENCE OF i IMerval Denvseo w�set and Aeatn <br /> �b� �a � G �'st,�4��' � 1 �vt.m <br /> DUE T0.OR AS A CONS OUENCE OF� � ��N�^�+^��� <br /> i <br /> � <br /> �c� � <br /> OTHER SIGNIFICANT CONDITIONS-ConGrtions contributirg to the Geath bW�wt�elated PART III IF FEMA�E.WAS THERE A 2a AUTOPSV 25.N/AS CASE AEFERRED TO ME AL <br /> FAR7 PREGNANCV M THE PAST 3 MONTHS? E%AMINER OR CORONER9 <br /> II <br /> (Ages�0-54) Yss No �es No �es No <br /> 26a 26b DATE OF INJURV /MO..Day.Yi.J 26c.HOUR OF IWURY 26d.DESCRIBE HOW INJURV OCCURHED <br /> � AccWeM � Untlelermin9d M <br /> � SukMe � Pentling 26e.INJURY AT WORK 261.PLAB E Obi���%N home•�arm,streal.fadory 26g.LOCATION STHEET OA R.F.O.NO. CITV OA TOWN STATE <br /> af bu Specn)J <br /> � Hom�ciCe InvesUgatwn ygg� p�p� <br /> 27a.DATE OF DEATH /MO.Day YrJ 28a.DATE SIGNED /MO..Day YN 28C TIME Of DEATN <br /> ` y4 �1'' (c -/O ��/9 a � M <br /> E`A' 27D.DATE N �MO..Day n./ 27c.71ME OF DEATM �k 28c.PRONOUNCEG DEAD /MO.Dey.Ycl 28d.PRONOUNCED DEAO /Haid <br /> ��� X �� X �:.w P�'i M ���� M <br /> 2�A.To the Dest d knowleage. atn occurr at ms ume,date and place and due ro Ine ��c� 28s.On tM Daais d�nminatwn aM�a nwstiq�Wn,in my opnbn OsaM occwrW N <br /> a �se1s1 stated. u a the 6me.W1a sM p4ce ua due b Ms cwselal e4MC. .. <br /> IS�naWre and Title► Wrs vM TiIN <br /> 29.DID TOBACCO USE CONTPoBU G HE DEATH7 30.a HAS ORGAN OR TISSUE DONATION yBE_E.,N CONSIDERED? 30.D WAS CONSENT 6MNTED7 <br /> � �ES � NO � UNKN , �i � VES I.R NO X � VES �NO <br /> .z.� <br /> 31.NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, NER'S PHVSICIAN OA COUNTV ATTORNEVI l7ype or Pnnf) <br /> � M.Sitki Copur,M.D. 116 West F i ey Avenue, P.O.Box 9804 Grand Island,NE.68802 <br /> 32a.REG�STRAR � 32b.DATE FILED BY REG�SJUN�y��1999 <br />�,tr�,� y ,������ 3� _ <br /> g�.� -�ee� of Lvt 5> <br /> ��;or� PC�.ca�C. �i 1 r.c���/ C�l�s��� C��`a-�-' O►`�. �1' <br />