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WWM ;rM COPYCARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTE14 !f CERTIFIES TFE BELOW TO BE A TRUE COPY OF THE OW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL MOft0ftl
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. al
<br />DATE OF ISSUANCE
<br />200403797 5/8/2003
<br />i &AWANT STAM
<br />LINCOLN, NEBRASKA HEALTH ANl#Ii7A{I
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAi�I stA
<br />VITAL STATISTICS' - -r
<br />CERTTFICATE OF DFATI3
<br />IS
<br />R .
<br />.5- 5c
<br />PORT
<br />03 04940
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2;'SE( ; ; .'
<br />3. DATE OF DEATH /Month. Day. Year)
<br />70
<br />Brostrom
<br />Female
<br />April 24, 2003
<br />. -.5
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />m
<br />(1
<br />UNDER 1 DAY
<br />rn
<br />C
<br />n=
<br />,Grand Island, Nebraska
<br />(Yrs.) 75
<br />°
<br />o va
<br />O
<br />r�-r
<br />26e. INJURY AT WORK
<br />506 -26 -0088
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />HOSPITAL ❑ Inpatient OTHER. ® Nursing Home
<br />Yes ❑ No ❑
<br />❑ ER Outpatient ❑ Residence
<br />81b. FACILITY -Name (Mnot insinuffi n, give streel and number)
<br />c a
<br />Center
<br />fD
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />r�
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />M
<br />Yes ® No ❑
<br />I
<br />Hall
<br />9a. RESIDENCE - STATE
<br />O.
<br />28d. PRONOUNCED DEAD (Howl
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER Ilncluding Zip T9801
<br />rn D y
<br />H
<br />Nebraska
<br />c,
<br />}.
<br />�
<br />o
<br />�,
<br />off'
<br />10. RACE - (e.g., White. Black. American Indian.
<br />rrN
<br />12. ® MARRIED
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE flf wile. give maiden name)
<br />ft.) (Spa �pr�
<br />Wn lte
<br />I
<br />(Span erman
<br />I G
<br />/Russian
<br />NEVER
<br />MARR
<br />°
<br />Ralph ,Brostrom
<br />14a. USUAL OCCUPATION /Give kindof wodr dare owing most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />C
<br />C^
<br />(Specify only highest grade completed(
<br />C)
<br />m
<br />`-�
<br />=n
<br />= M
<br />rco
<br />CDN
<br />or-+
<br />16. FATHER -NAME FIRST MIDDLE
<br />+-
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />m
<br />Benner
<br />Katherine Liebsack
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. or unk.) (e yes. give war and dates of services)
<br />lid
<br />Ralph Brostrom
<br />RE:
<br />Lot One (1), Block Four (4), Morris Second Addition to the City
<br />of Grand Island, Hall
<br />County, Nebraska
<br />WWM ;rM COPYCARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTE14 !f CERTIFIES TFE BELOW TO BE A TRUE COPY OF THE OW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL MOft0ftl
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. al
<br />DATE OF ISSUANCE
<br />200403797 5/8/2003
<br />i &AWANT STAM
<br />LINCOLN, NEBRASKA HEALTH ANl#Ii7A{I
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAi�I stA
<br />VITAL STATISTICS' - -r
<br />CERTTFICATE OF DFATI3
<br />IS
<br />R .
<br />.5- 5c
<br />PORT
<br />03 04940
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2;'SE( ; ; .'
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Lillian Catherine
<br />Brostrom
<br />Female
<br />April 24, 2003
<br />4. CITY AND STATE OF BIRTH id rot h U.S.A.. name country)
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />5b. MOS. I DAYS
<br />Sc. HOURS MINS.
<br />,Grand Island, Nebraska
<br />(Yrs.) 75
<br />October 26, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />22a. FUNERAL HQ0E -NAME
<br />8a. PLACE OF DEATH
<br />26e. INJURY AT WORK
<br />506 -26 -0088
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />HOSPITAL ❑ Inpatient OTHER. ® Nursing Home
<br />Yes ❑ No ❑
<br />❑ ER Outpatient ❑ Residence
<br />81b. FACILITY -Name (Mnot insinuffi n, give streel and number)
<br />St. Francis Memorial Health
<br />Center
<br />❑ DOA ❑ Other(Specdvl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />r�
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />M
<br />Yes ® No ❑
<br />I
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />28d. PRONOUNCED DEAD (Howl
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER Ilncluding Zip T9801
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />M
<br />Grand Island
<br />319 East 18th St.
<br />Yes JD No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc)
<br />12. ® MARRIED
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE flf wile. give maiden name)
<br />ft.) (Spa �pr�
<br />Wn lte
<br />I
<br />(Span erman
<br />I G
<br />/Russian
<br />NEVER
<br />MARR
<br />DIVORCED
<br />Ralph ,Brostrom
<br />14a. USUAL OCCUPATION /Give kindof wodr dare owing most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />❑ YES In NO
<br />15. EDUCATION
<br />(Specify only highest grade completed(
<br />Elementary o'Secondary 10.12) College 11 -4 or 5.1
<br />of wonlong life, even if retired/
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />'it" Im L
<br />Pharmacy Clerk
<br />Gibson Pharmacy
<br />1G
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Conrad
<br />Benner
<br />Katherine Liebsack
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. or unk.) (e yes. give war and dates of services)
<br />lid
<br />Ralph Brostrom
<br />190. mrUHMANI M ... A.-...
<br />ice, n¢, - ...r....,.v.. v.,. v..
<br />,v.. ... ..,--
<br />- ,
<br />319 East 18th St.,
<br />Grand Island,
<br />NE
<br />68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />(Ages 10.54) Yes 171 No
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21 c. CEMETERY OR CREMATORY NAME
<br />e
<br />* /�J ►
<br />26c. HOUR OF INJURY
<br />IN Burial
<br />11 Removal
<br />Aril 28, 2003
<br />Grand Island Cemetery
<br />22a. FUNERAL HQ0E -NAME
<br />El Suicide F Pending
<br />26e. INJURY AT WORK
<br />1. PLAe E OF_ I .URY %AS��P, farm. street. factory
<br />olm8cc bwl�dmng4.
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />❑
<br />Apfel- Butler- Geddes ❑Cremation Donation 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. (b). AND (c)) I Interval between onset and death
<br />PART h
<br />I
<br />I'
<br />DUE TO, OR AS A CONSEQUENCE OF* I Interval between onset and death
<br />iE M 'CW G C-AM S V6V� } Gf
<br />, . 1-. ,. = �5 ilC (►rl
<br />- I Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART711
<br />IF FEMALE. WAS THERE A
<br />24i, AUTOPSY
<br />ZS.:WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />-`= EXAMINER OR CORONER?
<br />11
<br />(Ages 10.54) Yes 171 No
<br />Yes r7l No
<br />Yea r No
<br />26a
<br />26b. DATE OF INJURY (Mo. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />2 SCRIBE HOW IN, JRY OCCURRED
<br />Accident Undetermined
<br />M
<br />El Suicide F Pending
<br />26e. INJURY AT WORK
<br />1. PLAe E OF_ I .URY %AS��P, farm. street. factory
<br />olm8cc bwl�dmng4.
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />@7a3DATE OF DEATH (Ado.. Day. Ycl
<br />28a. DATE SIGNED (MO.. Day. YO
<br />28b. TIME OF DEATH
<br />r�
<br />ay C)3
<br />r
<br />n' O
<br />M
<br />27b DATE SI NED (MO.. Day. Yrl
<br />270; TIME OF DEATH
<br />_..
<br />28c. PRONOUNCED DEAD iMa. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Howl
<br />��81`a3
<br />M
<br />M
<br />E
<br />27d. To the best of my knowlerige occurrad at the It . date and dace and due to the
<br />occu"'
<br />28e. On the basis of examination and,a investigation, in my opinion death occurred at
<br />°" causelsl stated.
<br />�F-+ /` ( /w-
<br />c> 6
<br />the time, date and place and due to the cause(s) stated.
<br />1l/nn
<br />(Signature and Title ) 0,
<br />1
<br />(Signature and TNe 10
<br />29.E DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />3Qt1u HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.DyWAS CONSENT GRANTED?
<br />�.
<br />❑ YES 13 NO ❑ UNKNOWN
<br />❑ YES In NO
<br />(�
<br />❑ YES 1+1I NO
<br />31, NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER "S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Peter Ledakis .D. 2116 W. Faidley Ave. Grand Island NE 68803
<br />32a REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />'it" Im L
<br />MAY 5 2003
<br />n V
<br />
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