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._-- - ` _. WHEN THlS COPY CARR/ES THE RA/SED SEAL OF THE NEBRASKA STATE DEP�IENT O,F�1f.�,�H,' /Z CERT/F/ES THE BEL OW TO BE A TRUE COPY OF AN OR/O/NAL RECORD�l-fjLf W/1'H THE 5T�# DEPARTMENT Of HEALTH,BUREAU Of V?AL STAT/ST/CS, WH/CH/S TH�#EGAL DEPO�f�OR1�f�ff V?AL RfCORDS. - - _ - DATE OF/SSUANCE , ��, : � = NOV 2 7 1995 = _ " " - ASS/5��"', - '�A� ' L/NCOLN,NEBRASKA NEBRASKA Dl�ARrM�YT * �i�#/. ' STATE OF NEBRASKA—DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS �' 9"1��QC��? CERTIFICATE OF DEATH � vv �7 � DECEDENT-NAME FIRST MIDDLE LAST 2 SEX Mary Elizabeth Freeman Female 3DANovembermll,N 1995 < CITV qN0 STATE OF BIRTH �nnd n US q..nyne�pinpy� Sa AGE-Laat BxttWay UNDER t YEAR UNDER i DAV 6.DATE OF BIR7H iMprye pay.Year/ Denver, Colorado �rs� 86 So Mos � w�s x.H«,AS MINS June 27, 1909 � 7 SOCIAL SECURTIV NUMBER Ba PLACE OF DEATN � 508-01-9947 MOSPITAL � inpaGeM OTHER � NursingHOme Bp FACILITV-Nam� InnormsMutbn.g�vesneerarrdnumber/ ❑ Epp�pe�t�� ❑ ResiAence � St. Francis Medical Center ❑ ooA ❑ a„e„s�,,�. Bc GTV TOWN OR�OCATION OF pEqTH 8tl INSIDE CITV LIMITS Be COUNTV OF DEATH Gramd Island _� �� No � �Hall _ ___ 9a RESIDENCE•STATE 9E COUNTV 9t CITV.TOWN OR LpCqTION gtl.STREET AND NUMBER /lnt� ''�^9zb�ode� 9e INSIDE CT'UMITS Nebraska Hall Grand Island 1741 S. Blaine 68803 �� X[� �� �0 RACE-le.g..Whrte.&ack.American InAian 11.ANCESTRY le.g.Ilalian.Mexican.German.etq 12 �MAqRIED ❑WIDOWED 73 NAME OF SPOUSE pJ w�le gne rriaben neme� ek.l�SOecdyl ISOenNI White German MARER DIVORCED Arthur M. Freeman 1ta USUALOCCUPATION iGrvekmtldw�awdp'eOunnymosl tOb KINDOFBUSINES$INDUSTRV 15 EDUCATION �$pec� onl hi d wwkrng hM.e�en il remedi h Y 9�9rade compkteGl Rece tionist Medical Offices E�01dryO17-T-ary10-�2� ca,�,,.,o„-, 16 fATHER-NAME FWST MIDDIE UST t 7 MOTMER fIRST L` MIDDLE MAIDEN SURNAME Clyde Essick Boyer Nelle Alice Cacklev 1B WAS DECEASED EVER IN US.ARMED FORCES? 19a.INFORMANT-NAME I�es.no a unk.� IM yes.gne war aM aates d servces� NO ---- Arthur M. Freeman 190 INFORMANT MAIUNG ADDPESS ISTREET pq R.F D.NO..CITV OR TOWN.STATE.ZIP� �, 1741 S. Blaine, Grand Island, Nebraska 68803 . MBALMER-SIGNATURE 8 LICENSE NO 21a.MET/lOp QF p$pp$ITION 21b.DATE 21 c CEMETERV OR CREMATORV NAME `°Q'Q'Q"�a�'u��yC.e� ��4'� �8iiri81 ❑�,��a� Nov. 14,1995 Westlawn Memorial Park 228.FUNERAL YpME-NAME 2 7 tl.C E M E TERV OR CREMATORY LOCATION CITV OR TOWN STATE Livin ston—Sondermann F.H. ❑�'°^�0on ❑°onaiwr Grand T_sland, Nebraska �220.FUNERAL HpME ADDRESS ISTREET OR R.F.D.NO_CITV OR TOWN.STATE,ZIp) 505 West Koenig, Grand Island, Nebraska 68801 23. IMMEDIA7E CAUSE IENTER ONIV ONE CAUSE PEA LINE FOR IaL Ib1.AND(c�� i PART , !� InlBnal pelwee�p��antl tleath � � (.�.�'.e� , �d�u�.e�r: � Ia1 .Q p � DUE T0,OR AS A CONSEOUENCE OF I x v � Interval onset antl ceatn f01 � _._.__G:J�Tv^.C�i 0.SA:.001.iEC:ie:�GE�.= I � - � imerva�anwear aon m�onerm� I�I � OTHER SIGNIFICAN7 CONDiT10N5-Condrtqns camiMfirg 10 me tleam Dut nq relatetl PART III IF FEMA�E.WAS THERE A 2a AUTpPS� ' PART 25.WAS CASE REFEHRED TO MEDICAL 11 YPfiEGNANCV IN THE PAST 3 MONTHS? � EXAMINER OR CORONER% �(A9es�0-511 Ves No Ves No Ves Np n'a 26b DATE OF INJURY /Mo.Day.Yt/ 26c HpUP OF IWURY 26C.DESCRBE HOW INJURY OCCURRED � AcciCeM � Unda�ermineC M � Su�tuh � Penping 26e IN,IURV AT WORK 261.PLACE OF.�UHV-��,.farm.sireet.facbry 26g.LOCATION STREET OR R.F.D.NO CI7v OR TOWN STATE � ❑ ❑ ollice build erc / Hom,ciAe Investga0on Yq� � � 2)a.DATE OF DEATH /AAO.Day YrJ 2Ba.DA7E SIGNED �MO.Dav n� . 28� TIME OF DEATH . November 11,1995 ��,'=J 27E DATE SIGNED /MO Dav✓�� 2�c.TIME OF DEATH 8 N c¢, M � g 6`� 2& PRONWNCED DEAD IMO Day,YrJ 2gy,pqONOUNCED DEAD /HOUn Y�° � November , 1995 8:20 P.M. �a�� i g "' g�� i a 27a To ttie best ol my kno aeapi occ retl at the Ume.Aa�e antl o��e anA due io Me M causnsi SuNO. 7 ' / °°� � On me baws d exammaUOn anG p /1 / ~° '' me nme.Oare ane dace ara tlue a tl�us�e,yoon.�s'�aqnan tleau�«curred a� IS napue an0 Tide� ' G V IS �T�I 29 DID 7pgACCO USE CONTRIB E Tq THE DEATMT ; 3p.a HAS ORGAN OR TISSUE DONAT BEEN CONSIDERED� 30.0 WAS CONSENT GRANTED� � � VES NO/ � UNKNONM H � VES Np ❑ � YES �NO 31 NAMEANDADDRESSOF IERIPHVSIppN,CORpNERSPHV$IClqNpqCWN7YATTOqNEVi ;Tryep�Prmry � John A Wagoner Jr MD, 800 Alpha Street, Grand Island, Ne 68803 32a REGISTfUR 320.DATE FiLED Bv REGiSiMR /MU..pwy yi� J NOV 2 01995 � .