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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQMUVMS6RVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE66RD ON.�JI,E=V1[/TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECT/QN, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS c DATE OF ISSUANCE MAY 8 2002 � LINCOLN, NEBRASKA 200405828 HEALTH AND HfAW1AN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERMFM RNANCEANDSUPPORT VITAL STATISTICS 02 05234 CERTIFICATE OF DEATH I DECEDENT - NAME FIRST MIDDLE LAST 2. SEX - 3. DATE OF DEATH (Mont. Day Year) Raymond C. Ol Aril 30 20 d. CITY AND STATE OF BIRTH tNnot m USA, name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6, DATE OF BIRTH /Mont. Day Year) Gage County, Nebraska Yrs.I 80 November 8, 1 5b MOS DAYS 5c. HOURS MIS 7. SOCIAL SECURTIY NUMBER Be . PLACE OF DEATH 508 -30 -2190 HOSPITAL © Inpatient OTHER ❑ Nursing Home PART PREGNANCY ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name pt not institution. give street and number! St. Francis Medical Center ❑ DOA ❑ Other(Soecdyl 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes [ No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zp Codel INSIDE CITY LIMITS Nebraska Hall Cairo 1"9e. 511 South S camor�824 Yes No ❑ 10. RACE -(e.g., White., Black. American Indian. 11. ANCESTRY (e.g.. Italian, Mexican, German, etc) 12. MARRIED ❑ Wit OWED ' NAME OF SPOUSE (lt wde. give maiden name) etc.) (Specify) (Specify) American "merican NEVER DIVORCED ❑ MARRIED T Jean M. Krueger 14a. USUAL OCCUPATION (Give kind of work done during most tdb. KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed) of pntkW li,e. even d reared) _ Elementary or Secondary (012) College (1 4 or 5� 1 16. FATHER -NAME FIRST MIDDLE LAST '-' -- - 1 MOTH R FIRST MIDDLE MAIDEN SURNAME Anton Oltman Ethel Grace Eckerd is, . WAS DECEASED EVER IN U ARMED F7p� R�O�ES? 19a INFORMANT - NAME L� es. no. or uri Ill yes. gi daCiWrerviForce WWII Jean Oltiman YE 27c TIME OF DEATH 19b. INFORMANT NTALIM&SS I (SINEETORRFD NO_ CITY OR TOWN. STATE. ZIPI 511 South Sycamore Cairo NE 68824 20. ER - SIGNAT NSE NO,i(fl&r g ==��TT l/ 21 a. METHOD OF DISPOSITION 21b. DATE 21, CEMETERY OR CREMATORY NAME cAf UBurial ❑Removal 5/3/2002 Mt. Pleasant Cemetery 22a. FUNS AL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel -O' Brien - Straatmann F.H. ❑ Cremation ❑ Donation Cairo Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) P.O. Box 126 Wood River, NE 68883 I [J. t UAUJt IEN 1111111 1111 1A111 11H 1I11 FVH Ial, Ibl. AND let) Interval between onset and death PART ` I lal f�.�i� DU OR A ONSEOUENCE OF: Interval between onset and death (b) a& O 1mor\ ' 0- i -3 V, DUE TC.1IDR AS A CONSEOUENCE OF Interval between onset and dear, C % C (c) l t-21cj\ OT ER SIGNIFICA T CONDITIONS - Conditions contributing to the death bud not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER? l 1 (Ages 10 -54) Yes No Yes No Yes No 26a. 26b. DATE OF INJURY (Mo.. Day Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED DAccident ❑ Undetermined M ❑ Suicide F] Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - At home. farm. sueet. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes No 1:1 office building. etc. ( Speciy/ 27a. DATE OF DEATH (Mo.. Day Yr.) 28a. DATE SIGNED /Mo.. Day Yr.l 28b TIME OF DEATH < A pril 30, 2002 $ z M v > 27b. DATE SIGNED (MO. Day. Yr) 27c TIME OF DEATH 28c. PRONOUNCED DEAD iMo.. Day, Yr./ 28d. PRONOUNCED DEAD (Hour! May 2, 2002 7:52am M J o M 8 27tl. To the best o .death occurred at th date and ce and due to the 28e. On the basis of examination and or investigation, in my opinion death occurred at cause(sl stat ° 5 the time, date and place and due to the cause(sl stated. (Signature and Title) ► ' (Si nature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TO T E �ES rH_ 30. a H ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ NO WN ❑ YES �O ❑ YES ZINO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) Dr R an Crouch, MD 800 Al ha St Grand Island NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) MAY 7 2002 South Seventy Feet (S 70') of Lot Two (2), Block One (1), Cairo Mayfield Village 8th Addition, Hall County, Nebraska.