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".
<br />�
<br />3. DATE OF DEATH !Month. Day.. Year/
<br />Glenn W. Staab
<br />Female
<br />June 24, 2004
<br />4. CITY AND STATE OF BIRTH !//twtn U.S.A. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Monts. Day. Year)
<br />(
<br />MOS. DAYS
<br />5o HOURS' MINS.
<br />April 12, 1920
<br />Berwyn, Nebraska
<br />I
<br />7. SOCIAL SECCURRTIYNUMBER
<br />Be. PLACE OF DEATH
<br />508-48 -8692
<br />HOSP_RAL: Inpatient OTHER: ❑ Nursing Home
<br />❑ -ER Outpatient ❑ Residence
<br />Bb. FACILITY -Name /N not ins6Yution, give street and number/
<br />;0
<br />r)
<br />C)
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yee A No ❑
<br />Hall
<br />9a. RESIDENCE-STATE
<br />9b. COUNTY
<br />go. CITY, TOWN OR LOCATION
<br />gd. STREET AND NUMBER /lncludkVZlp Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />323 N Ruby Ave., 68803
<br />Y. A NO ❑
<br />10. RACE - (e.g., White. Black, American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, Ger;;W7;Z7
<br />Z MARRIED ❑ WIDOWED
<br />7�'
<br />13, NAME OF SPOUSE (d.11,, give maiden name)
<br />r)nc�
<br />�pec �NI
<br />lie 61 an/American
<br />NEVER DIVORCED
<br />Norma M. Staab
<br />White
<br />MARRI
<br />14a. USUAL OCCUPATION /Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed(
<br />Elem@dely or Secondary 10 -121 College (1 -4 or 5-1
<br />of working life, even it retired!
<br />Farmer
<br />Farming
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alta (NMI) Swancutt
<br />Arthur L. Staab
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />dates 3/5/1942
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) It yes. give war and of services)
<br />1U.S.
<br />Norma M. Staab
<br />D
<br />to
<br />19b, INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />323 N Ruby Ave., Grand Island, Nebraska 68803
<br />;,
<br />c� --_�i
<br />21b. DATE 21c.
<br />ry
<br />per.
<br />06/25/2004
<br />Central Nebraska Cremation Servic
<br />( Not Embalmed)
<br />❑ 8uria1 ❑ Remkwal
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />--c o
<br />o
<br />A
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, - STATE, ZIP)
<br />3213 W North Front St Grand Island, NE, 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tal. (b), AND (0) I Interval between onset death
<br />/and
<br />PART A c GA t _ o,^ G S I f � v
<br />I �rI , , // /��
<br />(al
<br />r DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />n I
<br />fbl -20
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE WAS THERE A 2
<br />AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />�s
<br />IN THE PAST 3 MONTHS?
<br />, EXAMINER OR CORONER?
<br />( ` T (� (Ages
<br />10 -54) Yes No
<br />Yes D No Yes No
<br />26a.
<br />26b. DATE OF INJURY /MO.. Day. Y,)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLAe E I INJURY �At homg, farm. street. factory
<br />ollfi6cc bu SPecnYl
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /MO.. Day. Yr/
<br />CAI
<br />28a DATE SIGNED /MO.. Day. Yr)
<br />vt;
<br />nc Li, LC�y
<br />= Y
<br />m
<br />n r
<br />o
<br />-e
<br />27b. DATE SIGNED /Ma.. Day. Yr/
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /howl
<br />�
<br />8£ o
<br />y/
<br />of
<br />Z3
<br />=
<br />3
<br />v
<br />g
<br />°
<br />~
<br />rid to Me
<br />27d. To the best of my knowledge. death cu od aapieT
<br />289. On the basis of examination and,or investigation, in my opinion death occurred at
<br />causels) stated.
<br />° b
<br />the time, date and place and due to the cause(sM stated.
<br />1
<br />!",(Signature and Tmel ►
<br />CD
<br />29. DID : CO USE CONTRIBUTE TO THE TH? 30.a
<br />HAS OR AN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type wPdnq
<br />David R. Colan, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />32a. REGISTRAR -
<br />32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.)
<br />JUL = 6 2004
<br />n
<br />.A
<br />W
<br />o
<br />Cn
<br />Index against: Lot Six (6), in Block Thirteen (13), in Packer and Barr's Addition
<br />to the City of Grand Island, Hall County, Nebraska.
<br />WHEN n*S COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND14,144iQ ItywEs
<br />SYSTEPA IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC.(! 2N Elit,WTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST( E1 i__IGf /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -'
<br />ftADATE OF ISSUANCE
<br />����2004 2004075.39 NLEYC9QPE�t
<br />aA1ffi7ANf4- fATIr"►s t
<br />LINCOLN, NEBRASKA HEAL THANO#IUFIA ;W
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE]iVf $T
<br />VITAL STATISTICS "- /�
<br />CERTIFICATE OF DEATH = 0 `'t 07254
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH !Month. Day.. Year/
<br />Glenn W. Staab
<br />Female
<br />June 24, 2004
<br />4. CITY AND STATE OF BIRTH !//twtn U.S.A. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Monts. Day. Year)
<br />(Yrs.) 84 5b.
<br />MOS. DAYS
<br />5o HOURS' MINS.
<br />April 12, 1920
<br />Berwyn, Nebraska
<br />I
<br />7. SOCIAL SECCURRTIYNUMBER
<br />Be. PLACE OF DEATH
<br />508-48 -8692
<br />HOSP_RAL: Inpatient OTHER: ❑ Nursing Home
<br />❑ -ER Outpatient ❑ Residence
<br />Bb. FACILITY -Name /N not ins6Yution, give street and number/
<br />r
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other /Specuvl
<br />Bc, CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yee A No ❑
<br />Hall
<br />9a. RESIDENCE-STATE
<br />9b. COUNTY
<br />go. CITY, TOWN OR LOCATION
<br />gd. STREET AND NUMBER /lncludkVZlp Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />323 N Ruby Ave., 68803
<br />Y. A NO ❑
<br />10. RACE - (e.g., White. Black, American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, Ger;;W7;Z7
<br />Z MARRIED ❑ WIDOWED
<br />7�'
<br />13, NAME OF SPOUSE (d.11,, give maiden name)
<br />etc.) fSpecify)
<br />�pec �NI
<br />lie 61 an/American
<br />NEVER DIVORCED
<br />Norma M. Staab
<br />White
<br />MARRI
<br />14a. USUAL OCCUPATION /Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed(
<br />Elem@dely or Secondary 10 -121 College (1 -4 or 5-1
<br />of working life, even it retired!
<br />Farmer
<br />Farming
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alta (NMI) Swancutt
<br />Arthur L. Staab
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />dates 3/5/1942
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) It yes. give war and of services)
<br />1U.S.
<br />Norma M. Staab
<br />Yes Army 11Z11/1945
<br />19b, INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />323 N Ruby Ave., Grand Island, Nebraska 68803
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETFAY OR CREMATORY NAME
<br />06/25/2004
<br />Central Nebraska Cremation Servic
<br />( Not Embalmed)
<br />❑ 8uria1 ❑ Remkwal
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />Cremation ❑ Donation
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, - STATE, ZIP)
<br />3213 W North Front St Grand Island, NE, 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tal. (b), AND (0) I Interval between onset death
<br />/and
<br />PART A c GA t _ o,^ G S I f � v
<br />I �rI , , // /��
<br />(al
<br />r DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />n I
<br />fbl -20
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE WAS THERE A 2
<br />AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />�s
<br />IN THE PAST 3 MONTHS?
<br />, EXAMINER OR CORONER?
<br />( ` T (� (Ages
<br />10 -54) Yes No
<br />Yes D No Yes No
<br />26a.
<br />26b. DATE OF INJURY /MO.. Day. Y,)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLAe E I INJURY �At homg, farm. street. factory
<br />ollfi6cc bu SPecnYl
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /MO.. Day. Yr/
<br />28a DATE SIGNED /MO.. Day. Yr)
<br />2Bb TIME OF DEATH
<br />nc Li, LC�y
<br />= Y
<br />a<
<br />�N
<br />M
<br />27b. DATE SIGNED /Ma.. Day. Yr/
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /howl
<br />�
<br />8£ o
<br />y/
<br />of
<br />v M
<br />=
<br />M
<br />g
<br />°
<br />~
<br />rid to Me
<br />27d. To the best of my knowledge. death cu od aapieT
<br />289. On the basis of examination and,or investigation, in my opinion death occurred at
<br />causels) stated.
<br />° b
<br />the time, date and place and due to the cause(sM stated.
<br />1
<br />!",(Signature and Tmel ►
<br />( S" nature and TNe ►
<br />29. DID : CO USE CONTRIBUTE TO THE TH? 30.a
<br />HAS OR AN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type wPdnq
<br />David R. Colan, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />32a. REGISTRAR -
<br />32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.)
<br />JUL = 6 2004
<br />
|