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200406060 WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SERVICES SYSTEA4 IT CERTFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL MN WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST - -old /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 6/8/2004 - w- LINCOLN, NEBRASKA HEALTHAND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEA _f VITAL STATISTICS a g 4 0 5533 CERTIFICATE OF DEATH __. _ _ 1. DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Monet. Day. Ysaq Bell Jean Harders Female May 18, 2004 4. CITY AND STATE OF BIRTH )moth USA. name country) 5a AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) St. Paul, Nebraska nre'172 5b "10S I DAYS Se. HOURS' MANS. Dec. 8, 1931 7. SOCIAL SECURTiY NUMBER Be. PLACE OF DEATH 507 -1433 HOSPRAL - 9i- Inpadem OTHER: ® Nursing Home -36 ❑ ER Outpatient ❑ Residence ID. FACILITY -Name (iynot insEih". give sreer and number/ Park Place Nursing Home ❑ DOA ❑ Omer (Specdvi 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes ❑X No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER /including Zip Cade) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 610 N. Darr 68803 Yee ® No ❑ 10. RACE - (e.g, While. Black. American Indian. 11. ANCESTRY (e.g.. Malian. Mexican. German, ea) 12 MARRIED ❑ WIDOWED 13. NAME OF SPOUSE 10 wile. give maiden name) etc.) (Specify) White (' ") English NEVER DIVORCED Raymond Herders 14a. USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specily only highest grade complefisd) of working Ift even it retriso Day Care Provider Home Day Care Elementary or Secondary (0.121 College 11 -4 or 5.1 6 16. FATHER -NAME FIRST MIDDLE LAST t7. MOTHER FIRST MIDDLE MAIDEN SURNAME Clyde Hood Sarah Studley ,1& WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes, no. Dr unk.) (e yea. gtiie war And dates 6f services) N I Raymond Harders 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP( 118 S. Ingalls #410 Grand Island, NE. 68801 20. EMBALMER - SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME s�i3� s ®may ❑Removal May 24, 2004 Westlawn Memorial Park 22a. FUNERAL HOME/NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel - Butler- Geddes E] Cremation ❑Donal Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIPI 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE CAUSE IENTER ONLY ONE CAU PER LINE FOR (al. MI. AND Ic)) Interval between onset and death PART 1 / / �j / /��, _ ✓ '/ c�u�+ ( V� /l /P/Yx6rs�irof /! c+9 -• _ //r!t /`° / i^r ,fi;/ (a1 DUE TO, OR A A CONSEQUENCE OF Interval between onset and death (b) DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death I I (cl OTHER SIGNIFICANT CONDITIONS - Conditions contributing the death but not related PART III IF FEMALE WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART _� ` �� s�� /�� ' _ PREGNANCY 11 :f2 �/ / "� - ( IN THE PAST 3 MONTHS? i;e ENAMINER OR CORONER? F I LK ", (Ages 10 -54) Yes No Yes No Yes No 26a 28b. DATE OF INJURY (Mb.. Day. Yc� 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M Suicide Pending 26e. INJURY AT WORK 2N. PLiVC OF INJaUIRY - N lldnte, farm. street factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ d5 1tanF SpsCayl 27a. DATE OF DEATH (Ma. Day. Yr) 28L DATE SIGNED (Ale.. Day. Yr) 28b. n 'O P DEATH May 18 2004 r M 27b. DATE SIGNED (Mo. Day. Yr.) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Aria. Day, Yr.) 28d. PRONOUNCED DEAD (Four) May 18 2004 2 13am M w =9 M 27d. To the best of my knowledge. death curred at ti19 tirtre, tlale antl place and due to tin 289. On the basis of examination and,or investigation, in my opinion death occurred at causers) sWed. b the time. date and place and due to the cause(s) stated. (Signature and Tito - (Signature and Title 29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES © NO ❑ UNKNOWN ❑ YES © NO ❑ YES 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Typo orPM0 Jane McDonald M.D. 800 Alpha Ave., Grand Island, NE. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Ma. De,. Yr.) MAY 21 2004 I) • Lot Three (3) and the West Sixty Feet (60') of Lot One (1), Block Fifteen (15), Scarff's Addition to West Lawn, Grand Island, Hall County, Nebraska.