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Rev 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 200404758 <br />VITAL STATISTICS <br />f1IUv'rTVTf1AM nV TYPa rU <br />a� <br />C <br />O <br />U <br />O <br />T <br />C <br />0 <br />U <br />O <br />N <br />M <br />a) <br />cis <br />O <br />F- y <br />zE <br />W <br />p c <br />Lid i0 <br />0.9 <br />W y <br />0 J= <br />LL a <br />0.0 <br />T <br />W m <br />5 <br />Q <br />Z <br />U. <br />CO <br />M <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATK tMonth. Day. Year/ <br />Wilma May Shull <br />Female <br />March 9, 2.001 <br />4. CITY AND STATE OF BIRTH 111 nol an U.S.A.. name country) <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH iMori t Year) <br />MOS. I DAYS <br />5c. HOURS' MINS. <br />Alma, Nebraska <br />(Yral 5b. <br />78 <br />(D]ay. <br />March 22 , 1722 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />❑ Inpatient OTHER: Q Nursing Home <br />505 -52 -5504 <br />HOSPITAL <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name (fl not institution, give street and number) <br />❑ DOA ❑ Other(Spealvi <br />St. Francis Memorial Health Center <br />8c. CITY, TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY Of DEATH <br />Grand Island, Nebraska Yes] Na ❑ Hall <br />9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code) 9e. INSIDE CITY LIMITS <br />Nebraska Hall G Island # 5 St. James Place 68803 Yes SP:-+ No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, etc) <br />® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE tit wife. give maiden name) <br />etc.) (Specify( <br />White <br />112. <br />(speciyl <br />American <br />I <br />NEVER DIVORCED <br />MARRI99 <br />Donald L. Shull <br />14a. USUAL OCCUPATION (Give kind of work dare during mast 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ISpeciy only highest grade completed) <br />Elemenly Secondary 10 -12) College It -4 or 5•I <br />1 L <br />of waking life, n itreirred) <br />f'omemaker <br />Domestic <br />16. FATHER -NAME FIRST MIDDLE - LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />a Samuel Sadler <br />Fay Cassell <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no. or unk.) tit yes, give war and dates of services) <br />Donald L. Shull <br />MAILING ADDRESS - ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) <br />L#5St. ames Place G n Island, Nebraska 68803 <br />_/ GNATU I! LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME <br />i I Burial ❑ Removal arch 13 2001 Grand Island Ci m Pry <br />22a. FUNERAL HO - NA 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel- Butler- Geddes ❑ °femedai ❑ o"- Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second Street Grand Island Nebraska 68801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (bl. AND (e)I I Interval between onset and death <br />PART I 1 ^ <br />^v <br />1 �CiG �1J <br />let <br />DUE TO, OR AS A CONSEOUENCE OF: I Interval been onset and death <br />I <br />I <br />(b) <br />Interval be <br />DUE TO. OR AS A CONSEQUENCE OF: between onset and death <br />I <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? <br />PARTw <br />es <br />,�j^�1 A (Ages 10 -54) Yes No Y No Yes No <br />28a. <br />b. DATE OF INJURY MO.. Day. Yr -1 <br />26c. HOUR OF`1NJ M Y <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident F� Undetermined <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />LLqq <br />Pok bupldi INJURY jASPeiify% - )arm. street. lactory <br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />❑ Homicide Investigation <br />Yes ❑ No ❑ <br />T261 <br />27a. DATE OF DEATF lMo.. Day. Yr) 28a. DATE SIGNED /MO.. Day. Yr.) 28b. TIME OF DEATH <br />DEAD /Hour) <br />27b. DATE SIGNED /Mo.. Day, rl 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (MO.. Day, Yr) 28d. PRONOUNCED <br />'6 ��►3 -Izo aaIto M �o M <br />g 8 investigation, in my opinion death occurred at <br />27d. To the best of my knowbtl e. de h occurred at the e, dat an place and due to the 26e. On the base of examination an <br />a to <br />causelsl stated. _ c� b the Gme, date and place and due to the causes) stated. <br />(Signature and Tide 0, Si nature and Title <br />29. DID TOOBBA}CCCO USE CONTRIBUTE TO THE DEATH'? _ 3Qa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br />IJ[I( YES ❑ NO ❑ UNKNOWN ❑ YES NO 0 YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( /Type or Print) <br />Dr. Kimberly A. Mickels 729 North Custer Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR /Ma. Day. Yr) <br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE <br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. <br />1 <br />FEL -BUTLER- GEDDES FUNERAL HOME <br />