|
O .54
<br />2. SEX
<br />3, DATE OF DEATH /Month. Day. Year)
<br />JelTrev Robert Theis
<br />Male
<br />March 12, 2004
<br />4. CITY AND STATE OF BIRTH Ill not in USA.. name country/
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />Hastings Nebraska
<br />�v
<br />C1
<br />C1
<br />L
<br />January 21, 1957
<br />7. SOCIAL SECURTIV NUMBER
<br />8a.• PLACE OF DEATH
<br />°e)
<br />HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home
<br />n
<br />m
<br />908 S Greenwich Ave.
<br />❑ DOA ❑ Other (spec,/vl
<br />8t. CtTV. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE
<br />Be. COU NTY OF DEATH
<br />Grand Island
<br />�LIMJ�S
<br />Yes
<br />C
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />Be. INSIDE CITY LIMITS
<br />Nebraska
<br />n
<br />=
<br />908 S Greenwich Ave., 68801
<br />Yes U No ❑
<br />10. RACE - (e.g.. While. Black, American Indian.
<br />11. ANCESTRY Ie.g.. Italian. Mexican, German, etcl
<br />on
<br />13. NAME OF SPOUSE (If wile. give maiden name)
<br />Wlllte I
<br />zech /German
<br />NEVER DIVORCED
<br />Trina Smith
<br />N -
<br />n
<br />C/)
<br />. KIND OF BUSINESS INDUSTRY
<br />_
<br />15. EDUCATION (Specify only highest grade completed(
<br />of working life. even if retired!
<br />Owner/Manager
<br />''
<br />Etementa; or Secondary f0 -12( College 11.4 or 5 -I
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />6
<br />Francis E. Theis
<br />F
<br />Rose M. Mazour
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Iga. INFORMANT - NAME
<br />(Yes. no or unk.) (It yes. give war and dates of services(
<br />z
<br />Trina Theis
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP(
<br />94Greenwich Ave., Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />r
<br />❑ Burial ❑ Removal
<br />03/14/2004
<br />Central Nebraska Cremation Servic
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Butler- Volland Funeral Home
<br />® Cremation ❑ Donahoe
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP(
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) Interval between onset and death
<br />CJ
<br />SHOTGUN WOUND TO THE HEAD IMMEDIATE
<br />DUE 70, OR AS A CONSEQUENCE OF Interval between onset and death
<br />1 (bl I
<br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />I
<br />Ic I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />1.7 A\
<br />Yes No
<br />26a.
<br />1U
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN.,JRV OCCURRED
<br />❑ Accident ❑ Undele-,ed
<br />3- 12-2004
<br />7 : 00 A M
<br />FTI
<br />ZE3
<br />26e, INJURY AT WORK
<br />26f. PLACE OF INJURY - At home, farm. street. factory
<br />We
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No EA
<br />ce building, etc. /SA iy)
<br />HOME
<br />908 S . GREENWICH AVE, GMM-0 ISLAND
<br />J
<br />27a. DATE OF DEATH (Mo.. Day. YO
<br />17-
<br />28a. DATE SIGNED /Mo.. Day Yrl
<br />28b. TIME OF DEATH
<br />ra,
<br />V . - 1 ,y/
<br />7:00 A
<br />M
<br />v -
<br />T-
<br />271, . DATE SIGNED /Mo.. Day. Yr.l
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Hourl
<br />3 -12 -2004
<br />8:50 A
<br />M
<br />$ Sw z z�
<br />o
<br />M
<br />27d. To the best of my knowledge. death occurred at the time. date and place and due to the
<br />28e. On the basis of examination anof r investigation in my opinion death occurred at
<br />_
<br />° ¢° o
<br />~
<br />causelsl stated.
<br />Co
<br />the cone, date and place a to the ca '
<br />N
<br />to
<br />�elsiplatetl.
<br />� L
<br />ISI nature and Title) It,
<br />ISi nature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />W ONSENT GRANTED?
<br />U3
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECRON, WNICHJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -rye
<br />DATE OF ISSUANCE "O-
<br />ANLEY S. COOPER
<br />3/31/2004 2 0 0 4 0 5 519 ASSISTANT STATE REGISTRAR-
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESMNA_ NCE $iJPPORT_
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH �- - 0 4 03530
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3, DATE OF DEATH /Month. Day. Year)
<br />JelTrev Robert Theis
<br />Male
<br />March 12, 2004
<br />4. CITY AND STATE OF BIRTH Ill not in USA.. name country/
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />Hastings Nebraska
<br />(Yrs.) 47 sb.
<br />Mos. DAYS
<br />5c. HOURS' MINS.
<br />L
<br />January 21, 1957
<br />7. SOCIAL SECURTIV NUMBER
<br />8a.• PLACE OF DEATH
<br />507-72-7193
<br />HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient Residence
<br />8b. FACILITY - Name (If not institution, give street and number/
<br />908 S Greenwich Ave.
<br />❑ DOA ❑ Other (spec,/vl
<br />8t. CtTV. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE
<br />Be. COU NTY OF DEATH
<br />Grand Island
<br />�LIMJ�S
<br />Yes
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />Be. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />908 S Greenwich Ave., 68801
<br />Yes U No ❑
<br />10. RACE - (e.g.. While. Black, American Indian.
<br />11. ANCESTRY Ie.g.. Italian. Mexican, German, etcl
<br />12. � MARRIED ❑ WIDOWF_D
<br />13. NAME OF SPOUSE (If wile. give maiden name)
<br />Wlllte I
<br />zech /German
<br />NEVER DIVORCED
<br />Trina Smith
<br />MARRIED
<br />14a. USUAL OCCUPATION (Give kind of work done during most 141b
<br />. KIND OF BUSINESS INDUSTRY
<br />_
<br />15. EDUCATION (Specify only highest grade completed(
<br />of working life. even if retired!
<br />Owner/Manager
<br />Auto Service Center
<br />Etementa; or Secondary f0 -12( College 11.4 or 5 -I
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Francis E. Theis
<br />F
<br />Rose M. Mazour
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Iga. INFORMANT - NAME
<br />(Yes. no or unk.) (It yes. give war and dates of services(
<br />No
<br />Trina Theis
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP(
<br />94Greenwich Ave., Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />( Not Embalmed)
<br />❑ Burial ❑ Removal
<br />03/14/2004
<br />Central Nebraska Cremation Servic
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Butler- Volland Funeral Home
<br />® Cremation ❑ Donahoe
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP(
<br />1225 N Elm Ave. Hastings, NE, 68901
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) Interval between onset and death
<br />PART
<br />SHOTGUN WOUND TO THE HEAD IMMEDIATE
<br />DUE 70, OR AS A CONSEQUENCE OF Interval between onset and death
<br />1 (bl I
<br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />I
<br />Ic I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />Yes F No X
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mid- Day. Yc/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN.,JRV OCCURRED
<br />❑ Accident ❑ Undele-,ed
<br />3- 12-2004
<br />7 : 00 A M
<br />SELF INFLICTED GUNSHOT
<br />Swcide ❑ Pending
<br />26e, INJURY AT WORK
<br />26f. PLACE OF INJURY - At home, farm. street. factory
<br />We
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No EA
<br />ce building, etc. /SA iy)
<br />HOME
<br />908 S . GREENWICH AVE, GMM-0 ISLAND
<br />27a. DATE OF DEATH (Mo.. Day. YO
<br />28a. DATE SIGNED /Mo.. Day Yrl
<br />28b. TIME OF DEATH
<br />ra,
<br />V . - 1 ,y/
<br />7:00 A
<br />M
<br />v -
<br />271, . DATE SIGNED /Mo.. Day. Yr.l
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Hourl
<br />3 -12 -2004
<br />8:50 A
<br />M
<br />$ Sw z z�
<br />o
<br />M
<br />27d. To the best of my knowledge. death occurred at the time. date and place and due to the
<br />28e. On the basis of examination anof r investigation in my opinion death occurred at
<br />_
<br />° ¢° o
<br />~
<br />causelsl stated.
<br />Co
<br />the cone, date and place a to the ca '
<br />�elsiplatetl.
<br />� L
<br />ISI nature and Title) It,
<br />ISi nature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />W ONSENT GRANTED?
<br />❑ YES ❑X NO F-1 UN
<br />❑ YES ® NO
<br />❑ YES NO
<br />I. rvHMt HrvU HUUHtJJ ur l.tn IYICn l r!'iTJII.IFn. I,VHVrvtn J 1111 J W - 4VVrvlr NI IU-T1 II yo-1-111
<br />SGT. COLE, WAND ISLA[Z POLICE DEPARTMENT, 131: SOUTH LOCUST STREET, GRAND ISLAND, NE 68801
<br />32a. REGISTRAR 321b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />MAR 3 00 2004
<br />W4110
<br />
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