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t <br />CQ <br />M <br />2 :3 <br />c_C S <br />ti <br />M <br />M <br />n <br />c <br />= D <br />M i <br />rj <br />r� <br />INK <br />0 <br />© z <br />rT1 <br />M <br />0 <br />200406060 <br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND *9W <br />MSERVICES <br />SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL <br />IIIVW_ WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7ISTT30 OtIIS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - DATE OF ISSUANCE <br />6/8/2004 200407456 <br />LINCOLN NEBRASKA HEALTH AND <br />NERVICL�SSAF1�f <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER\fICF�NII SUPPORT <br />VITAL STATISTICS 04 <br />CERTIFICATE OF DEATH V = <br />ry <br />c <br />r <br />N <br />O <br />'D <br />E--s <br />t-a <br />O <br />CD -4 r+ <br />c n [D <br />z rn PD <br />CL <br />o <br />o � <br />= m <br />CD <br />D C�7 C/1 <br />r � <br />r n <br />x <br />03 e-r <br />05533 <br />I. DECEDENT - NAME FIRST MIDDLE UST <br />2 SEX .. <br />3. DATE OF DEATH (Month. Day. Year) <br />Bell Jean Harders <br />Female <br />I May 18, 2004 <br />a. CITY AND STATE OF BIRTH (tl norn USA. name country) <br />5a AGE -Last Bkthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Monts. Day. Year) <br />MOS. I DAYS <br />5c. HOURS MINS. <br />St. Paul, Nebraska <br />(Vrs.l 72 5b. <br />Dec . 8 , 19 31 <br />7. SOCIAL SECURTIY NUMBER <br />8a PUCE OF DEATH <br />507 -36 -1433 <br />HOSPITAL -9.- Inpatient OTHER ® Nursing Hone <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name /M not institution, give straef and number) <br />Park Place Nursing Home <br />❑ ODA ❑ Other(Spech(mh <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Grand Island <br />Yes ❑X No ❑ <br />Hall <br />ga RESIDENCE - STATE _ <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER ltrncluding Zip Coda) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />610 N. Darr 68803 <br />Yes ® No ❑ <br />10. RACE - (e.g., White. Black. American Indian. - <br />11. ANCESTRY (e.g.. Italian. Mexican, German, am) <br />12 X❑ MARRIED ❑ WIDOWED <br />/Nwife. givemaidenname) <br />etc.) (Soealy) White <br />SpBcityl English <br />NEVER DIVORCED <br />�13,NAMEOFSPOUSE <br />Raymond Harders <br />14a. USUAL OCCUPATION (Give kind of work done during moss 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade compteted) <br />of working ife, even it retired) <br />Day Care Provider <br />Home Day Care <br />Elementary or Secondary 10 -12) College 114 or 5.1 <br />6 <br />16. FATHER - NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Clyde Hood <br />Sarah Studley <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT -NAME <br />a i'� ea. r.c. cr unk) (if ytls. give War e✓d dales W anevir:es) <br />No Raymond Harders <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP) <br />118 S. Ingalls #410 Grand Island, NE. 68801 <br />20. EMBALMER - SIGNATURE A LICENSE NO. <br />21a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME - <br />st13z.s <br />Burial <br />® ❑Berton <br />May 24, 2004 <br />Westlawn Memorial Park <br />22a. FUNERAL HOMEFNAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes <br />❑D'"""°" 11 D0n81an <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, NE. 68801 <br />IMMEDIATE CAUSE (ENTER ONLY ONE CA PER LINE FOR (al. ft AND (e)1 I Interval between onset and death <br />23. PART � <br />'�'! /" <br />�V /C /�/ha/'/� lie' //t Gs9C "'.. <br />//n <br />/�+��t1+° <br />fat /� / , i''v �fl /�1 •� <br />DUE TO, OR AS A CONSEQUENCE �OFG� 1 Interval between onset and death <br />-. <br />@I I <br />DUE TO. OR AS A CONSEQUENCE OF: Interval behw9en onset and dean <br />I <br />l <br />(c) I <br />OTHER SIGNIFICANT CONDITIONS - Cork ilbns contn'dAry the death but not related PART <br />PART <br />61 IF FEMALE WAS TFIEiiE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />_� �'/ - p��A7 / 'Z� G� PREGNANCY <br />�//7 "V iC! ( <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />(Ages <br />10 -54) Yes No <br />Yes No <br />Yes No <br />26a. <br />26b. DATE OF INJURY /MO.. Day Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />261. PIlAACEE ppF INJURY - farm, steel factory <br />buikting, <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />- - <br />Homicide Investigation <br />Yes.❑ NO ❑ <br />office etc. / <br />. <br />1 <br />27a. DATE OF DEATH (Ma Day Yc) <br />21a, DATE SOM (Aka. . Yr) - <br />28L TIME OF DEATR - <br />May 18 2004 <br />M <br />27b. DATE SIGNED (Mo. Day. Yr.) <br />27c. TIME OF DEATH <br />28C. PRONOUNCED DEAD (Ma. Day Yr.) <br />25d. PRONOUNCED DEAD /Fburl <br />> <br />k } <br />May 18 2004 <br />2:13am M <br />M <br />27d. To the best of my knowledge. death curred at the fire, date and place and due to the <br />28e. On the basis of examination and,or investigation, in my opinion death occurred at <br />12 v <br />cause(s) stated <br />a <br />the time, date and place and due to the causels) stated. <br />(signature and Tito - <br />(Signature and Tltle <br />29, DID TOBACCO USE CONTRIBU111 TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />❑ YES © NO ❑ UNKNOWN <br />❑ YES © NO <br />❑ YES Z14101, NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type prPri io <br />Jane McDonald M.D. 800 Alpha Ave., Grand Island, NE. 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.1 <br />MAY 21 2004 <br />I) - <br />The West Sixty r6rdt (W60') of Lots One (1) and Three (3) , Block Fifteen (15), Scarff's <br />Addition to West Lawn, Grand Island, Hall County, Nebraska. <br />O <br />N <br />O <br />O <br />s <br />O <br />s <br />CJ1 <br />CTS <br />6zb <br />