|
(�) 1* ;a n R
<br />X
<br />� y C h � Iv Fri
<br />°
<br />M- c�
<br />rrnn b N r C_ -' N z].
<br />n CA _ G r-1
<br />_ M �' r < CD
<br />CD
<br />i m _ _,V y c� O
<br />!-a x CD CD
<br />-.1 CrJ z
<br />p
<br />WHEN TM COPY CARRIES TM RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 !T CERTFIES TI£ BELOW TO BE A TRUE COPY OF THE ORIGINAL REC0RQ3OAIFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/S17ft.�T/CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE rte(
<br />AMLEY� COOPER
<br />5/13/2004 200407023
<br />A�SIS7'AI�SlATE REGl3#•HAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH - - _ - . . - n A n A a Q 7
<br />1. DECEDENT -NAME FIRST MIDDLE LAST 2
<br />2. SEX 3
<br />3. DATE OF DEA I M. Day Vsar/
<br />7004
<br />4. CITY AND STATE OF BIRTH /d no M U.S.A.. name country/ S
<br />Sa. AGE -Last Birthday u
<br />utb& 1 Y
<br />YEAR U
<br />UNDER 1 DAY 6
<br />6. DATE OF BIRTH IMoriM. Day. Years
<br />Sb. MOS. D
<br />DAYS 5
<br />5c. HOURS' MINS.
<br />(Yrs.l S
<br />1 J
<br />Grand Island Nebraska 8
<br />86 1
<br />June 14, 1917
<br />T SOCIAL SECURTIY NUMBER B
<br />Be. PLACE OF DEATH
<br />506 -09 -5601 -
<br />HOSPRAL: I
<br />Inpatient OTHER' Nursing Home
<br />❑ ER Outpatient - ❑ Residence
<br />8b. FACILITY - Name /H not inshfulion, give sheet and number) ❑
<br />Wed ewood Care Center ❑
<br />❑ DOA ❑ OIher /ter"'
<br />Sc. CITY. TOWN OR LOCATION OF DEATH 8
<br />8d. INSIDE CITY LIMITS B
<br />Be. COUNTY OF DEATH
<br />Grand Island Y
<br />Yes ❑ No ❑ H
<br />Hall
<br />go. RESIDENCE -STATE 9
<br />9b. COUNTY 9
<br />9c. CITY. TOWN OR LOCATION 9
<br />9d. STREET AND NUMBER ilnclud'ng Zip Code) 9
<br />9e. INSIDE CITY LIMITS
<br />Nebraska H
<br />Hall G
<br />Grand Island 1
<br />1#14 Chantilly, 68803 Y
<br />Yes [�] No ❑
<br />10. RACE - (e.g., White. Black. American Indian. 1
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc) t
<br />t2. (-j MARRIED ❑
<br />❑ WIDOWED 13. NAME OF SPOUSE (ll wile. give maiden name)
<br />etc.) IScecdyl. (
<br />(Speedy) l
<br />liY„I N
<br />NEVER D
<br />DIVORCED
<br />AR I
<br />14a. USUAL OCCUPATION /Give kind of work dorm owing mast 1
<br />14b. KIND OF BUSINESS INDUSTRY 1
<br />15. EDUCATION (Specify only highest grade completed)
<br />of workkrg Ids' oven it retired) E
<br />Elementary or Secondary 10 -121 College 11 -4 or 5 -1
<br />Maintenance Engineer H
<br />H 1
<br />11
<br />16. FATHER -NAME FIRST MIDDLE UST 7
<br />FIRST MIDDLE MAIDEN SURNAME
<br />John HuHe l
<br />7T�HE% F
<br />lsie E
<br />Elizabeth Mohr
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 1
<br />19a INFORMANT - NAME
<br />(Yes. no. or unlc) (if yes. give war and dates of services) 03/28/1945 --
<br />U- .o 1J I NCCi UN n.r.U. NU., UI I T UN I VWN. J I A 1 e. LIP(
<br />#4 hnill
<br />2Q EMBALMER •SIGNATURE 8 LEand Island. Nebraska 6! 1803 NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME
<br />(Not Embalmed) ❑.al ❑Removal 04/23/2004 Central Nebr. Cremation Services
<br />MIL FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home IX " ❑ " Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIPI
<br />3213 W North Front St Grand Island, NE. 68803
<br />23. IMME E CAUSE ` (ENTER LY ONE CAUSgeEJ4_LINE Fi -7x { \� la1. @I• AND kit Interval` between onset and death
<br />PART(
<br />DUE TO, OR AS A C N OUENCE OF \i Inerval between onset and death
<br />I
<br />(b)
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not rotated PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />11
<br />(Ages 10-541 Yes No Yes No Yes M No
<br />26a 26b. DATE OF INJURY /MO.. Day. Yr.) 26c. HOUR OF INJURY 126d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending 26e. INJURY AT WORK I 261. PJ,Aa ki INJMUcRY i homg, farm. street lacbry 26g. LOCATION STREET OR R.F.O. N0. CITY OR TOWN STATE
<br />Homicide Investigation Yes ❑ � ❑ t"n4 d1'l
<br />27a. DATE OF DEATH /Mo.. Day. Yrl 28a. DATE SIGNED /MO.. Day. Yr.) 28b. TIME OF DEATH
<br />- � �Q Al A i M
<br />$ a 27b. DATE SIGNED /Mo.. Day. Yrl 27c. TIME OFD TH � g 28c. PRONOUNCED DEAD IMO.. Day, Ycl I 26d. PRONOUNCED DEAD (Hour)
<br />aY
<br />8i M BuQiz M
<br />27d. 7o the best 0 y knowled e. Ut oceu time. date a p ce and due to the u 28e. On the basis of examination and,o investigation, in my opinion death occurred at
<br />causelsl stated. 'L ^ ", 8 . the lime, date and pace and due to the cause(s) stated.
<br />ISi nalure and Tide N �Y \ ` , �' `� (Signature and Title 0,
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3Da HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO UNKNOWN ❑ YES 0 ❑ YES 5 NO
<br />3i. NAmc MN ^uumcoo Vr- ilr- 1- To-AN, t•VnV J-T-N UN-UN I I AI I UNNCII Irype Or"M111
<br />John J. Cannella, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />"SD
<br />rs
<br />I
<br />3- �
<br />�3
<br />Za
<br />�v
<br />r
<br />7
<br />i
<br />n
<br />�e
<br />3213 W North Front St Grand Island, NE. 68803
<br />23. IMME E CAUSE ` (ENTER LY ONE CAUSgeEJ4_LINE Fi -7x { \� la1. @I• AND kit Interval` between onset and death
<br />PART(
<br />DUE TO, OR AS A C N OUENCE OF \i Inerval between onset and death
<br />I
<br />(b)
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not rotated PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />11
<br />(Ages 10-541 Yes No Yes No Yes M No
<br />26a 26b. DATE OF INJURY /MO.. Day. Yr.) 26c. HOUR OF INJURY 126d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending 26e. INJURY AT WORK I 261. PJ,Aa ki INJMUcRY i homg, farm. street lacbry 26g. LOCATION STREET OR R.F.O. N0. CITY OR TOWN STATE
<br />Homicide Investigation Yes ❑ � ❑ t"n4 d1'l
<br />27a. DATE OF DEATH /Mo.. Day. Yrl 28a. DATE SIGNED /MO.. Day. Yr.) 28b. TIME OF DEATH
<br />- � �Q Al A i M
<br />$ a 27b. DATE SIGNED /Mo.. Day. Yrl 27c. TIME OFD TH � g 28c. PRONOUNCED DEAD IMO.. Day, Ycl I 26d. PRONOUNCED DEAD (Hour)
<br />aY
<br />8i M BuQiz M
<br />27d. 7o the best 0 y knowled e. Ut oceu time. date a p ce and due to the u 28e. On the basis of examination and,o investigation, in my opinion death occurred at
<br />causelsl stated. 'L ^ ", 8 . the lime, date and pace and due to the cause(s) stated.
<br />ISi nalure and Tide N �Y \ ` , �' `� (Signature and Title 0,
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3Da HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO UNKNOWN ❑ YES 0 ❑ YES 5 NO
<br />3i. NAmc MN ^uumcoo Vr- ilr- 1- To-AN, t•VnV J-T-N UN-UN I I AI I UNNCII Irype Or"M111
<br />John J. Cannella, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />"SD
<br />rs
<br />I
<br />3- �
<br />�3
<br />Za
<br />�v
<br />r
<br />7
<br />i
<br />n
<br />�e
<br />3i. NAmc MN ^uumcoo Vr- ilr- 1- To-AN, t•VnV J-T-N UN-UN I I AI I UNNCII Irype Or"M111
<br />John J. Cannella, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />"SD
<br />rs
<br />I
<br />3- �
<br />�3
<br />Za
<br />�v
<br />r
<br />7
<br />i
<br />n
<br />�e
<br />
|