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<br />WHEN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE_CORLD2 FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS4ft -1'�T _1611FAMICH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />200403852
<br />AAILEY4. CCiGJ*R
<br />6/17/2003 ASSISTAMiEAqTAM OGIStRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYlTtM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN-$EMKES FINANCEAND SUPPORT
<br />VITAL STATISTICS - 03 J 0 6 7 5 7
<br />CERTIFICATE OF DRAIN
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH !Month. Day. Year/
<br />Genevieve
<br />NMN Maloney
<br />Female
<br />June 5, 2003
<br />4, CITY AND STATE OF BIRTH /Ilnot nr U.S.A., name country)
<br />�
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year/
<br />Lawrence, Nebraska
<br />Cemetery
<br />(Yrs.)
<br />87.
<br />March 25 , 1916
<br />Sb. MOS. DAYS
<br />Sc. HOURS' MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />Nebraska.
<br />508 -66 -0283
<br />268, INJURY AT WORK
<br />TAL: PI
<br />HOS:
<br />- - Inpatient OTHER ❑ Nursing Home
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />411 AF.Aj 11th St., P.O. Box 126,
<br />-_
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (N not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specdvl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />PART �'
<br />I
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />let 11 f
<br />Yes IN Np ❑
<br />I
<br />Hall
<br />9s. RESIDENCE - STATE
<br />9b. COUNTY
<br />i
<br />I
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. I7SIDECITY IMITS
<br />Nebraska
<br />Ball
<br />DUE TO, OR AS A CO1MQUtNC V
<br />Wood River
<br />300 Lilly, 68883
<br />Y ❑
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY leg.. Italian, Mexican. German, etc)
<br />12. ❑ MARRIED
<br />© WIDOWED
<br />13. NAME OF SPOUSE of wile. give maiden name)
<br />etc.) (Specify) White
<br />White
<br />(Specify)
<br />I
<br />German
<br />NEVER
<br />AR
<br />DIVORCED
<br />George Maloney (dec. )
<br />14a. USUAL OCCUPATION /Give kind of work done dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working li even ii;re�1
<br />I�omemaKer
<br />Domestic
<br />30.b WAS CONSENT GRANTED?
<br />Elementagor Secondary (0 -12) College 0 -4 or 5-1
<br />b
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Joseph
<br />Schutte
<br />Mary Vonhaus
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no, or unk.)
<br />llf yes. give war and dates of services)
<br />No
<br />James Maloney
<br />8500 Alda. Road, Wood River, NE
<br />68883
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />�,� 11227
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />EXAMINER OR CORONER?
<br />21c. CEMETERY OR CREMATORY NAME
<br />�
<br />®Bbhal
<br />❑Removal
<br />June
<br />9, 2003
<br />St. Mary's
<br />Cemetery
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apf el Funeral Home
<br />❑ cremation
<br />❑ Donation
<br />Wood River,
<br />Nebraska.
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />268, INJURY AT WORK
<br />26f. PLACE OF, INJURY - At hom6, farm. street. factory
<br />office udding, etc. /Specify
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />411 AF.Aj 11th St., P.O. Box 126,
<br />Wood River,
<br />Nebraska 68883
<br />23. IMMEDIA AUSE ( RLINLY ONE CAUSE PER LINE FOR Is). (b). AND (c)l I
<br />Interval between onset and death
<br />PART �'
<br />I
<br />28a. DATE SIGNED tMo.. Day. Yr.)
<br />I
<br />=
<br />let 11 f
<br />I
<br />M
<br />DUE TO. OR AS A CONSEOLIENI OF
<br />Q
<br />i
<br />I
<br />Interval between onset and death
<br />(b)
<br />28d. PRONOUNCED DEAD (Hour,
<br />I
<br />DUE TO, OR AS A CO1MQUtNC V
<br />June 9,2
<br />6:2 pm M
<br />Interval between onset and death
<br />M
<br />I
<br />.8
<br />°
<br />lot
<br />28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />o °
<br />PART OTHER SIGNIFICANT CONDITIO - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />^�
<br />(Ages /0 -54) Ves NO
<br />Yes No
<br />Yes Na
<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 />268, INJURY AT WORK
<br />26f. PLACE OF, INJURY - At hom6, farm. street. factory
<br />office udding, etc. /Specify
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />Yes No
<br />27a. DATE OF DEATH /Mp.. Day. Yr.) -
<br />28a. DATE SIGNED tMo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />=
<br />June 5,2003
<br />M
<br />o
<br />Q
<br />27b. DATE SIGNED /Mo.. Day. Yr)
<br />27e. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour,
<br />June 9,2
<br />6:2 pm M
<br />M
<br />s
<br />.8
<br />°
<br />27d. To Me best of my knowledge. death oc rred at the e, date nd ace d due to the
<br />28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />o °
<br />causefs) stated.
<br />v
<br />the time. date and place and due to the cause(s) stated.
<br />(Signature and Title) 10
<br />(Signature and Title
<br />29. DID TOGA USE CONTRIBUTE TO THE D
<br />30.a S ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO
<br />U NOWN
<br />❑ YES 2NO
<br />❑ YES NO
<br />....... .......���- 11"1 - wnvncno rn.ora.wn- wurvi r n i wnrvcrl rrypu -1
<br />Ryan D. Crouch D.O. 890 Alpha, Grand Island, NE 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.)
<br />
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