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Z m l.� Ux ("'t 2. SEX 3. DATE OF DEAW 5 M. Day Year) M ( Not Embalmed) 24 AUTOPSY _ C Sa. AGE -Last Birthday U 1 YEAR UNDER 1 DAY 8. DATE Of BIRTH lAlontlr. Day. Year) Sb. MOS. DAYS m �� r r Grand Island Nebraska Z CD M 3213 W North Front St Grand Island NE 68803 v rn -nz °m r=irn D rn _ ` y co ❑ ER Outpatient Residence 8b. FACILITY - Name (M not rnsatut/on, give street and number) Wed ewood Care Center o ❑ DOA ❑ Otherl$Qeodw r a ed. 1N618cCITY UNATS Ux ("'t 4 RE- RECORDED' X00407328 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, fT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S�E'�TAW -WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE ��ANLEY� COJQP�R 5/13/2004 20040 7 0 2 3 0SISTAAifg7A:TE INEGISTAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A34D SUPPORT VITAL STATISTICS __ CERTIFICATE OF DEATH n A n A C Q 7 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEAW 5 M. Day Year) 21c. CEMETERY OR CREMATORY NAME ( Not Embalmed) 24 AUTOPSY i 4 o � Sa. AGE -Last Birthday U 1 YEAR UNDER 1 DAY 8. DATE Of BIRTH lAlontlr. Day. Year) Sb. MOS. DAYS m �� r r Grand Island Nebraska STATE. ZIP) CD M 3213 W North Front St Grand Island NE 68803 � rn -nz °m 506 -09 -5601 rn _ ` y co ❑ ER Outpatient Residence 8b. FACILITY - Name (M not rnsatut/on, give street and number) Wed ewood Care Center o ❑ DOA ❑ Otherl$Qeodw r a ed. 1N618cCITY UNATS tie. COUNTY OF DEATH cn Yes ®Ne ❑ t-� x 9a. RESIDENCE -STATE 9b. COUNTY D 9d. STREET AND NUMBER l)ncludktg Zip Code) 9e. INSIDE CITY LIMITS Nebraska Ilan I Grand Islan d 1#14 Chantiliv. 68803 rrlF> 4 RE- RECORDED' X00407328 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, fT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S�E'�TAW -WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE ��ANLEY� COJQP�R 5/13/2004 20040 7 0 2 3 0SISTAAifg7A:TE INEGISTAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A34D SUPPORT VITAL STATISTICS __ CERTIFICATE OF DEATH n A n A C Q 7 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEAW 5 M. Day Year) 21c. CEMETERY OR CREMATORY NAME ( Not Embalmed) 24 AUTOPSY i 4 4. CITY AND STATE OF BIRTH /lt not in U.S.A. name country) Sa. AGE -Last Birthday U 1 YEAR UNDER 1 DAY 8. DATE Of BIRTH lAlontlr. Day. Year) Sb. MOS. DAYS 5c. HOURS' MIN& °rani°" ❑ DOnawn (Yrs.l Grand Island Nebraska STATE. ZIP) M 3213 W North Front St Grand Island NE 68803 June 14 1917 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH (ENTER LY ONE CAUS, i�LINE F lal. (b). AND (c)) 506 -09 -5601 HOSP AL ❑ Inpatient OTHER: Nursing Home ` /�� • ` _ ❑ ER Outpatient Residence 8b. FACILITY - Name (M not rnsatut/on, give street and number) Wed ewood Care Center I � e IJ N ❑ DOA ❑ Otherl$Qeodw 8c. CITY. TOWN OR LOCATION OF DEATH._ - -. - - - - - ed. 1N618cCITY UNATS tie. COUNTY OF DEATH Grand Island Yes ®Ne ❑ Hall 9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER l)ncludktg Zip Code) 9e. INSIDE CITY LIMITS Nebraska Ilan I Grand Islan d 1#14 Chantiliv. 68803 Yes @ Nd ❑ 10. RACE - le.g., White. Black. American Indian, 11. ANCESTRY le.g.. Italian. Mexican, German, etc) 12 n MARRIED El WIDOWED 13. NAME OF SPOUSE /N wife. give maiden name) etc.) IScecify). fSPeclfYI ICJ NEVER DIVORCED - R 1 Lucille M. Petersen 14a. USUAL OCCUPATION /Give kind of work done dmirg most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working life, even it redroo Elementary or Secondary 10 -121 College Il -4 or 5.1 Maintenance Engineer Hospital 1 I 1& FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME John Hurls Elsie Elizabeth Mohr I& WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yea. no. or unk.l lit yes. give war and dates of services) 03/28/1.945 -- World War 11 08 1/1 Ve, Ymeille M. Hurley 20. EMBALMER - SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME ( Not Embalmed) 24 AUTOPSY ❑ Burial ❑ Removal 04/23/2004 Central Nebr. Cremation Services 22a. FUNERAL HOME -NAME Yes Nolj�jj Yes - NO R' 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Home 26c. HOUR OF INJURY °rani°" ❑ DOnawn Gibbon, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) M 3213 W North Front St Grand Island NE 68803 Suicide 7 Pending Homicide Investigation 23. IMME CAUSE PART ` (ENTER LY ONE CAUS, i�LINE F lal. (b). AND (c)) I Interval between or" and death w 1 ` /�� • ` _ (al V� 'V V I � e IJ N DUE TO, OR AS A CQN OUENCE OF I Interval between onset and death (b) I DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART if I PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? 24 AUTOPSY 25. =ERE REFERRED TO MEDICAL EXAMINER OR CORONER? (Ages 10-54) Yes NO Yes Nolj�jj Yes - NO R' 26a. 26b. DATE OF INJURY (W. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED F1 Accident ❑ Undetermined M Suicide 7 Pending Homicide Investigation 26e. INJURY AT WORK Yes ❑ No ❑ 261. olfi e E OFINJURY %At horrne, farm. street. factory olfi bu,ldi SP�nl') 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 28b. TIME OF DEATH na �� a(z) M 0`155 27b. DATE SIGNED (Mo.. Day. Yr.) 27c. TIME OF TH g y 28c. PRONOUNCED DEAD (Ab.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour) S 2 ✓`�J�+ O V M ¢ z Sw� M 27d. To the best ot4fry knowiedqe-diii occu a time. dale arilkPlir and due to the v 28e. On the basis of examination and,or investigation, in my opinion death occurred at causelsl stated. ° the time, data and place and due to the causefs) stated. ISi nature and Tale N .1�/ \ ` \ �' `� 00-iSignaltuni, and T'ele P. 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 7a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 130.b WAS CONSENT GRANTED? ❑ YES ❑ NO UNKNOWN ❑ YES NO ❑ YES 17CL NO - 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Pnnp ""-'\ John J. Cannella, M.D., 729 N Custer Ave., Grand Island, NE 68803 rn o N o 0 s � O 3 o m N W Z O 'SO ij If it 2- -� . a �3 I ZI N V • w co -s v n