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�� � <br /> ^�' <br /> �� rn n n <br />�' � n C� Z n 2 ct� � � � <br /> I� m c�i� � � CD o -i �' `v <br />`,( �_ n N � (ti � �--� C D Cp <br />�/' �� � \J � m A � � rn Q c�. <br /> � �s�-,�". --C p � y <br /> a, G, O �l CD <br /> T'�_ � � z t�n <br /> �- � �-: � F-+� <br /> t`�:' Z rrt <br />� ��� r� �1 -� Ts Q7 1-�► C <br /> ���7 y <br /> C_? da � r � � <br /> r n ►-+ <br /> c� ;:� � co <br /> t;: N x O7 .�-r <br /> � '�� O <br /> F-+ �...,D.. p <br /> � h' ln 1--+ <br /> (-� C/) <br /> � <br /> W�N TH3 COPY GI�S TFE RA/8ED 3EAL OF THE NEBRASKA HEALTH AND HUNUUIl.�S �.S�o <br /> S1�S1F.A�IT CERTFE3 TFE BELOW TO BE A TRUE COPY OF THE OR/Q/NAL RECOR�€!��_ <br /> 7�E NEBRASKA HEALTH AND HUMAN SERVICES SY3TEM,VITAL STATI3TIC3 S��-�-�_ <br /> THE LEQAL DEP031TORYFOR VITAL RECORDS = - - <br /> DATE OF/SSUANCE �' _ <br /> -=�. � <br /> SEP 2 3 1999 9 9 1116 01 ���R �== - <br /> ASSISTAIV��TE RE013TIiAR:`= =_ <br /> UNCOLN,NEBRA3KA I�EALTHAND HUMAAi�ER�IlCE8_SYSTEA!E-' � - <br /> STATE OF NEBRASKA-DF:PARTMENI OF E�1LTH AND H{JMAN SERVICES�Fi�GE e�f@�SLT�DRT== <br /> VITAL STATISTICS ==- - - -- <br /> CERTIFICATE OF DEATH � _ <br />.DECEDENT•NAME FIRST M1DDlE LAST 2.SEX 3.DATE OF DEATH /Mom2 Day.Vea�) <br /> l.CITY ANO STATE Of&RTM ,„,�Gle MwIJIJU I �� �pGE•Le7t BiMdeOC�UNDER 1 VEAR U`NDEH DAY 6.DAT O�F BIRTHei/Mp�Day.oYea�) 1999 <br /> �YB.) � Sb.MOS. DAVS Sc.HWRS' MINS. NOVeIIWCL 24� 1915 <br /> Cairo, Nebraska 83 <br /> 7.$OCIAI SECURTIY NUMBER Ba.PUCE OF DEATH <br /> 506-09-6824 MOSPITAL � ��OE�ieM OTHER � Nursing Hwne <br /> Bb.FACILITY-Name /Hndinsnfu(an.givesbeelarrdnumbeQ � EROulpeUern � Restlence <br /> � DOA � Other/SOeatyr <br /> St. Francis Medical Center <br /> T OCAT��N OF�EA1N � - - . � - . - - _ .- .�C�.!l�ISI,^..E C1TY��75 Re.COUNTV OF DEATN <br /> Grand Island "°° � "° � H 11 <br /> 9a.RESIOENCE-STATE 9b.COUNTV 9C.CITV,TOWN OR LOCATION � 90.STHEET AND NUMBER pnclu7�ngZip Cadel 9e.INSIDE CITV LIIMTS <br /> Nebraska Hall G I 1 d 23 W. 8 h 6 Ol `"°�0 "°❑ <br /> 10.RACE-�e.g.,White.Blatk.Amencan InCian. 11.ANCESTRY le.q..llalian.MeKican.GMman.etc) 12.�MARRIED ❑WIDOWED 13.NAME Of SPOUSE /I/wife.give maiden name/ � <br /> � <br /> re.ytc�..,)ISPeclh) (��NI NEVER DIVORCED <br /> YYllly�e i R - Dora Wiese � <br /> l. <br /> 1<a.USUAL OCCUPAiION /G��e kindol work Cone duling mnsl 14b.KIND OF BUSINESS INDUSTRV 15.EDUCATION �Speciry only MgMSt graCe comdetedl <br /> d Morkmg lile,even ilreniedl Elemernary or Secontlary 10-t2) � CoNege 11-4 or 5•I �` <br /> Owner/O rator Weldin Com n 12 <br /> 16.FATMER-NAME FIRST MIDDLE UST 17.MOTHER FIRST MIDDLE MlUDEN SURNAME <br /> Valentine Koch Effie Stan e �� <br /> 18.WAS DECEAS��EVER iN U.S.ARMED FORCES? -1 9 19a.INFORMANT NAME <br /> IYes.rw.a unk.) IN yes.q�ve war and Gales of servicesl 1�/��/�"� � " - <br /> Yes World War II 09 18 1945 Dora Koch - Wife <br /> . <br /> t9b.INFORMANT MAILING ADORESS ISTREET OR R.F.O.NO.,CIN OR TOWN.STATE.ZIP) <br /> 1123 W. Eighth Stz•eet, Grand Island, NE 65801 <br /> ALMEF-S�GNATUAE G I�CENSE NO. � ` 21a METHODOF DISPOSiT�Or. 2tb.DATE I?1c.CEMETERV OA C�iEMATOA� NnME <br /> J <br /> �,,, ���� �8�;,, ��,��a� Sept. 11, 1999�Westlawii Mem. 'Park Cemetery � r ` <br /> .FUNERAL ME-NAME 2�tl.CEMETERY OA CREMATOA�LOCATION GTY OR TOWN STATE v.1 <br /> Apfel-Butler-Geddes F.H. ❑°r�'°" ❑°ona1io" i Grand Island, Nebraska <br />??t FUNFRAI MOME ADDAESS (STREET OR R.F.D.NO..CITV OF TOWN.STATE,ZIP) � <br /> 1123 W. Second Street, Grand Island, NE 68801 _ <br /> p3. IMMEDIATE CAUSE (EN7ER ONLV ONE CAUSE PER LINE FOR lal�Ib�.AND�c�) � Interval betwcen onset arW tleam <br /> PART �� / I � � <br /> ,,, ! �/G!.(i�� a u/-� <br /> DUE T0.OR A CONSEOUENCE OF � I �mr al between onset anE tleath \ <br /> I \ <br />. . .. . "' ._"'_.__"_'_'_.�._� `�\ <br /> Ibl . . _.._ -_ .._. ._ I _- � � <br /> DUE 70.OR AS A CONSEOUENCE OF� i �nterval between onset antl Geatn � <br /> � -�w <br /> ��) � <br /> OTHER S�('iNIFICA :ONOITIONS-CondNions CIXWibutieg l0 t�e dlaM Oul rol relatetl PART tll IF PEMALE.WAS THERE A ' 2a.AUTOPS� 25.E AM�INER ORFCORONER MEDICAL d <br /> PART PREGNANCY IN THE PAST 3 MONTHS � <br /> ° /VZG!f1�c1,Vr,�- <br /> �Ages 10-54) Yes No Yes No Yes � No <br /> 25a, Z6b.DATE OF INJURV /Ma..Day.Yc/ 26e.HWF OF INJURV 26A.DESCRBE HOW INJURY OCCURRED <br /> � AtcideM � U�de�ermmetl �„� <br /> � Smcitle � Pe�tlmg N�e_�NJURV AT WORK 261.P Ce�I�,,�J�RY%N ,_ .larm.sveet.facfay 26g.LOCATION STREET OR Rf.D.NO. piV OR TOWN STATE <br /> � Homipde Investiqat�on Yes❑ No❑ � � <br /> 27a.DATE OF DEA7H �Mo.Day.Yc1 / 2Ba.DATE SIGNED (Mo..Oay YrJ 28b.TIME OF DEATH <br /> �'�� ! / �w M <br /> �� ��� <br /> `i�i 27b.DATE SIGNED (Ab..DaY.ri.l 27a TIME OF DEATM 28c.PRONOUNCED DEAD (MO..Dey.Ycl 28d.PRONOUNCED DEAD /HOUd <br /> � ��< <br /> �� 3 D�59 ¢�� <br /> �� ' ' M M <br /> 8 <br /> ° 27d.Ta tne Dest d my krawbd9e. acc rred�tl�s 6 , ate a e Aue to Ine 28e.On ihe basia d ecsminaGOn and�a invesfigatbn,in rtry opnbn Cealh oceurred at <br /> eauselsl siateE. ~c>n Ma fime.Oa�antl qace arW aue w the oause�sl stated. <br /> �naturs enE Tide► �nalure anC Title <br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATM? 30.s F1AS OROAN OR TISSUE OONATION�BEEN`CONSIDERED? 30.b WAS CONSENT GRANTED? <br /> � VES �NO � UNKNOWN � VES . � R n0 � VES NO <br /> T� <br /> 31.NAME I WD ADORESS OF CEiiTIFIlt FMYSICUW,CORONER'S PMYSICIAN OR CW NTY ATiORNEYI (Type P'Pi6N1 <br /> Dr. David R. Co n M.D. 729 . Cust G nd <br /> 32a.REGISTRAR _ � 32b.DATE FILED BY REGISTRAR (lb..D�y.Yr./ <br /> � .. �AAA <br />