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I \ 1 G � i J Z n c l V WHEN THIS COPY CARIMS THE RAISED SEAL OF THE NEBRASK&4WALMAW HUMAN SERVICES SYSTEA4 IT CERTFES THE BELOW TO BE A TRUE COPY OF AFWbM0&&fftVRD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEA&7_WkL MM. TKO FFUION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 200403-674 = == _ - - _ - LBY S. COOPER MAR 91999 = = -- ASS1STAhTW4W REGISTRAR LINCOLN, NEBRASKA HALfi#1 Efil SEMK/ICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEAL VICES FWANCB AND SUPPORT VITAL ST&ISTMS -_ _- ". CERTIFICATE 01== NT - NAME FIRST MIDDLE LAST } 2.• SEX 3. DATE OF DEATH /AN Yawl 4. CITY AND STATE OF BIRTH (Nnof it U.S.A.. name aou'lli St. AGE - Last Birthday UNDER 1 YEAR UNDEH 1 DAY d. UAI t: D' IKH 1 n m art. wy. tart T ,, 1%, 4- T. ILT -}„- = � 1r (Yrs.i r, � 5b. MOS. I DAYS Bd. HOURS � MINS. Ma V 19 , 1943 - _l TIY NUMBER _. _ .. ea. PLACE OF DEATH HOSPITAL: ❑ Inpaderd OTHER: ❑ Nursing Home -54 -4770 - -- ® ER ONW Raaidence me /H or t wa/Non• W1'e aweal and m mbwj rIALTSE I n Tl 11T. and death E] DOA ❑ DOW (8pecdyi ancis Medical 1 I jbI R LOCATION OF DEATH M = N. COUNTY OF DEATH d Island (cl OTHER SIGNIFICANT CONDITIONS - CaMaio°s corehou6rq to Me death but not related Yes ®N° ❑ �1 O 9b. COUNTY z M CA CITY LIMITS 26a. y o Cp 26d. DESCRIBE HOW INJURY OCCURRED 72.1N,19iDE ' NO❑ Nebraska Hall Grand Island 1309 Sherman PI803 10. RACE - (e.g.. White, Black. Ameridan Indian, ANCESTRY le.g.. Iu6an. Mexican. German, etc) j 12. MARRIED ❑ WIDOWED ' Inc.) (Specify) white D NEVER DIVORCED MARRIED F-1 113. Carol J. S t o bb e aade conwlwdl 14a. USUAL OCCUPATION (Give kindol work done dtalrlp matt 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify a10 � �o� Owner/Operatic Office Products 12 16. FATHER -NAME FWST MIDDLE (TTI ' John y (� 16. WAS DECEASED EVER IN U.S. ARMED FORCES? y 26c. PRONOUNCED DEAD (Mo- Day. Yil 7 m 1 V�• 27d. To tM best d my knowbdge. death occurted n dre dm.. dare and dace end due W the :C Yes 112_27-6n/12-2_6_-66 calmNs) stated IS nahas and TiW nature end Tide 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b 171`1 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? E] YES ❑ NO � UNKNOWN 191I. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) o 'Ti 1309 Sher C)- 20. EMBALMER - SIGNATURE 8 LICENS5 NO. J 21a METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME � Burial ❑ Removai 2-16-99 G City C e me r p a. U ERAL HOME - NAM - 21d CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE Kleine Funeral Home El Cremation ❑Dprid1i, Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP( _- _-_ -... .. _- rrand °'.....� ........... ..... T-q1414A,,,_NF-I Intwrval banvaan onset and death D � rT1 r L C I \ 1 G � i J Z n c l V WHEN THIS COPY CARIMS THE RAISED SEAL OF THE NEBRASK&4WALMAW HUMAN SERVICES SYSTEA4 IT CERTFES THE BELOW TO BE A TRUE COPY OF AFWbM0&&fftVRD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEA&7_WkL MM. TKO FFUION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 200403-674 = == _ - - _ - LBY S. COOPER MAR 91999 = = -- ASS1STAhTW4W REGISTRAR LINCOLN, NEBRASKA HALfi#1 Efil SEMK/ICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEAL VICES FWANCB AND SUPPORT VITAL ST&ISTMS -_ _- ". CERTIFICATE 01== NT - NAME FIRST MIDDLE LAST } 2.• SEX 3. DATE OF DEATH /AN Yawl 4. CITY AND STATE OF BIRTH (Nnof it U.S.A.. name aou'lli St. AGE - Last Birthday UNDER 1 YEAR UNDEH 1 DAY d. UAI t: D' IKH 1 n m art. wy. tart T ,, 1%, 4- T. ILT -}„- = � 1r (Yrs.i r, � 5b. MOS. I DAYS Bd. HOURS � MINS. Ma V 19 , 1943 - _l TIY NUMBER _. _ .. ea. PLACE OF DEATH HOSPITAL: ❑ Inpaderd OTHER: ❑ Nursing Home -54 -4770 - -- ® ER ONW Raaidence me /H or t wa/Non• W1'e aweal and m mbwj rIALTSE I n Tl 11T. and death E] DOA ❑ DOW (8pecdyi ancis Medical 1 I jbI R LOCATION OF DEATH 8d. INSIDE CITY LIMITS N. COUNTY OF DEATH d Island (cl OTHER SIGNIFICANT CONDITIONS - CaMaio°s corehou6rq to Me death but not related Yes ®N° ❑ Hall ga. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 111d, STREET AND NUMBER I/mkialkV Zip Code) CITY LIMITS 26a. 26b. DATE OF INJURY (Ma. Day Yc) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED 72.1N,19iDE ' NO❑ Nebraska Hall Grand Island 1309 Sherman PI803 10. RACE - (e.g.. White, Black. Ameridan Indian, ANCESTRY le.g.. Iu6an. Mexican. German, etc) j 12. MARRIED ❑ WIDOWED NAME OF SPOUSE (N wIPe. prv►rrMidarl rrerrre/ Inc.) (Specify) white III* (Specify) 12 n1jgh NEVER DIVORCED MARRIED F-1 113. Carol J. S t o bb e aade conwlwdl 14a. USUAL OCCUPATION (Give kindol work done dtalrlp matt 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify a10 of et rk'ing kb, even Nrefiredl 0q)4:--) EMmerKary or Secondary 10 -t2) -. College I1.4 a 5 -I 12) Owner/Operatic Office Products 12 16. FATHER -NAME FWST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME ' John Dzingle Sally Mae Stanczyk • 16. WAS DECEASED EVER IN U.S. ARMED FORCES? y 26c. PRONOUNCED DEAD (Mo- Day. Yil tga. INFORMANT - NAME M (Yea. nd. or unk.) Id yea, give war and dares Of services) :25 M in oecland M 27d. To tM best d my knowbdge. death occurted n dre dm.. dare and dace end due W the v 28e. On t1re basic d axaminas - a' a the nme. dace and place Yes 112_27-6n/12-2_6_-66 calmNs) stated IS nahas and TiW nature end Tide 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b Carol J. T)7inale 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? E] YES ❑ NO � UNKNOWN 191I. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) [] YES IR NO , 1309 Sher 20. EMBALMER - SIGNATURE 8 LICENS5 NO. J 21a METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME Burial ❑ Removai 2-16-99 G City C e me r a. U ERAL HOME - NAM - 21d CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE Kleine Funeral Home El Cremation ❑Dprid1i, Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP( _- _-_ -... .. _- rrand °'.....� ........... ..... T-q1414A,,,_NF-I Intwrval banvaan onset and death 23. IMMLIPIAIG-0E , -... �...... -. - .._- ..___. _.. _. _ .. 1 PART I I (al I n Tl 11T. and death DUE TO. OR AS A CONSEQUENCE OF 1 I jbI DUE To. OR AS A CONSEQUENCE OF.� I (cl OTHER SIGNIFICANT CONDITIONS - CaMaio°s corehou6rq to Me death but not related 24 AUTOPSY fAMINER IASE OR CORRONER MEDICAL PART PREGNANCY MALE. PAST 3 MONTHS? (Age510 -541 Yee NO Yes NO Yee 7 NO 26a. 26b. DATE OF INJURY (Ma. Day Yc) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined M Suicide Pending 26e. INJURY AT WORK 261. P E �i IOW, B,RY - At hgne. )arm. street. laclpry �GacNyl 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Invesagaom YM ❑ -1:11 bu Ce 27a. DATE OF DEATH (Mo.. Day Yr/ 28a DATE SIGNED (MO. Day. Yr) 28b. TIME OF DEATH <> 3 -4 -99 AI- 9:25 a M �< 27b. DATE SIGNED (MO.. Day Yr 1 27C. TIME OF DEATH y 26c. PRONOUNCED DEAD (Mo- Day. Yil 28Q PRONOUNCED DEAD /h/p.Tl M 2 -12 -99 :25 M in oecland M 27d. To tM best d my knowbdge. death occurted n dre dm.. dare and dace end due W the v 28e. On t1re basic d axaminas - a' a the nme. dace and place $l f calmNs) stated IS nahas and TiW nature end Tide 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b G ED? 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? E] YES ❑ NO � UNKNOWN YES NO - [] YES IR NO , 31. NAME AND ADDRESS OF CEHTIFIER (PHYSICIAN. CORONER "S PHYSICIAN OR COUNTY ATTORNEY) /Type or Rrntl