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_o O m �z V7 1 `= 04 O O n P N*N TINS CippyCARMS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND SERVICES SYSMF4 R CERIMS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL: RECD- .FINE IMTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALS I i3 THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCEJl LINCOLN, NEBRASKA 200409057 HEALTH #JKSTEIIIyr STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVXWF$iAl�fd l TIISUPP IlkT VITAL STATISTICS A nao�rr -A'1rV usTU R 4 08933 1. DECEDENT -NAME FIRST MIDDLE — _ —LAST — _ _ — _ _ 2 SE)( 3. DATE OF DEATH (Month. DAY. Year) Louis M. Knapp Male Aug 10 2004 - 4. CITY AND STATE OF BIRTH lentil U.S.A.. nam cmift) Sa. AGE -.Lad MM IRY UNDER 1 YEAR ,UNDER 1 DAY & DATE OF BIRTH (A40Mk Gay. Veer/ - (Ym) 5Q MOS, I DAYS sc. HOURS : .. MINS. Mar 9 1933 C':tCn m 7. SOCIAL SECURnY NUMBER - - S& PLACE OF DEATH HOSPITAL ® WPaft OTHER: p' Nursing Home 508 -32 -8.039 ER•ah4elient Resider" ., p DOA COWtspscdyr 8b. FACILITY - Name - (Mlldf emelo A ow easel arrdramr I Saint Francis Medical Center . Se. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS as. COUNTY OF DEATH ., .. Grand Island _ -yea pp : Na a Hall - - ft RESIDENCE •STATE 8b. COUNTY ft. CITY, TOWN OR LOCATION _ 8d STREET AND NUMBER [#WkA[2VZ0 Code) 9e. INSIDE CITY LIMITS E Nebraska Hall Grand Island 1805 N. Howard 68803 Yea No ❑ o emi(S -c'") I NEVER DIVORCED Jose Nine Anderson White American '14& USUAL OCCUPATION (G1ve kmdd Burk dme dm*V fiWW 14Q KIND OF BUSINESS INDUSTRY 15. E�D''U1°CA�TI'ON (SPecrly only Wade eompWatil d e�arii v ft ~ frodrsdl � :. E X22 Secondary Io-12) Cdlaga l 2 or 5 -I c Plumber 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Charlie Knapp Maxine V. Fleshman 1& WAS DECEASED EVER IN U.S. ARMED FORCES?.. 18a INFORMANT - NAME (Yee. no. or u1k.) IN yes. give *m and dON of servkesl Yes �104 22 1953 04/07/1955 - Josephine A. Knapp 1 Sb. INFORMANT' MAMAVB ADDRESS (STREET ORRF.D. NO- CITY OR TOWN. STATE. 21P1 8 N. Howard Grand Island, NE. 68803 W T21 �/�/j 92 Xp Bald p R.moval Aug 13 , 2004 Rose Hill Cemetery 22& FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CRY OR 70VM1 STATE m 2 CA 3005 South Locust Street Grand Island NE 68801 rn m (� O 1bl E TO. AS A CONSEQUENCE OF: I Interval arhsa and death . DU NC 'L,f. Col; �. (c) REFERRED OTHER SIGNFTCANT CONOITKN4S - GW Mau C2�nQ b the death but rrbtrNalad P ATM IF FEMALE WAS THERE A 24. AUTOPSY 25. WWAS CA E OR CORONER? PART PREGNANCY IN THE PAST 3 MONTHS? m 28& Mb. DATE OF INJURY W Dry• Yr) 28a HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Aceded UrhdelarmWSd 0 28e. INJURY AT WORK 1t • lem. street hCCry . 28L P IKE QF M ARV A. 284 LOCATION STREET OR RF.D. NO. CITY OR TOWN STATE Srddds Pehhdtrr9 cow Yes O No p °z ( DATE OF DEATH (Ma Day. Yr.) n 28& DATE SIGNED (M- Gay. W..) 0 w ...M S�3 _ jv n CA Ae. DATE BONED [Al. Dq• Yrl nME of DEATH `� 28a PRONOUNCED DEAD /Afa Gry. Yr -) 28d. PRONOUNCED DEAD /Fburl 71 O 1a 1 O E / ✓r� To the beet d my tawladge. death accurral at tm0. data and place and due to the 3 / v a 28e. On are Dash a d once an dus to hvestigallm calea(s) t my oPl^pn death occurred at the Nme. dale and place and due b the causMsl dried. . cat -e(sl alelad. L1 J - -1 to 3 r D DID TOBACCO (JO CONSIDERED? WAS CONSENT GRANTED? . p YES p NO YES NO p YE S 40 UNKNOWN co D 32a _ 0 13M AUG 18 2004 Cil ._. co cn CD CM A crz � o W _o O m �z V7 1 `= 04 O O n P N*N TINS CippyCARMS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND SERVICES SYSMF4 R CERIMS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL: RECD- .FINE IMTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALS I i3 THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCEJl LINCOLN, NEBRASKA 200409057 HEALTH #JKSTEIIIyr STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVXWF$iAl�fd l TIISUPP IlkT VITAL STATISTICS A nao�rr -A'1rV usTU R 4 08933 1. DECEDENT -NAME FIRST MIDDLE — _ —LAST — _ _ — _ _ 2 SE)( 3. DATE OF DEATH (Month. DAY. Year) Louis M. Knapp Male Aug 10 2004 - 4. CITY AND STATE OF BIRTH lentil U.S.A.. nam cmift) Sa. AGE -.Lad MM IRY UNDER 1 YEAR ,UNDER 1 DAY & DATE OF BIRTH (A40Mk Gay. Veer/ - (Ym) 5Q MOS, I DAYS sc. HOURS : .. MINS. Mar 9 1933 Palmer, Nebraska 71 7. SOCIAL SECURnY NUMBER - - S& PLACE OF DEATH HOSPITAL ® WPaft OTHER: p' Nursing Home 508 -32 -8.039 ER•ah4elient Resider" ., p DOA COWtspscdyr 8b. FACILITY - Name - (Mlldf emelo A ow easel arrdramr I Saint Francis Medical Center . Se. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS as. COUNTY OF DEATH ., .. Grand Island _ -yea pp : Na a Hall - - ft RESIDENCE •STATE 8b. COUNTY ft. CITY, TOWN OR LOCATION _ 8d STREET AND NUMBER [#WkA[2VZ0 Code) 9e. INSIDE CITY LIMITS E Nebraska Hall Grand Island 1805 N. Howard 68803 Yea No ❑ 10. RACE - (ag, W O. Black. American Wdan. 11. ANCESTRY 10.4. IlaNsn. Main• German. e10 12. ® MARRIED. ❑ WIDOWED. I& NAME OF.SPOUSE (M' e1i4.17Ae maiAln name) emi(S -c'") I NEVER DIVORCED Jose Nine Anderson White American '14& USUAL OCCUPATION (G1ve kmdd Burk dme dm*V fiWW 14Q KIND OF BUSINESS INDUSTRY 15. E�D''U1°CA�TI'ON (SPecrly only Wade eompWatil d e�arii v ft ~ frodrsdl � :. E X22 Secondary Io-12) Cdlaga l 2 or 5 -I c Plumber 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Charlie Knapp Maxine V. Fleshman 1& WAS DECEASED EVER IN U.S. ARMED FORCES?.. 18a INFORMANT - NAME (Yee. no. or u1k.) IN yes. give *m and dON of servkesl Yes �104 22 1953 04/07/1955 - Josephine A. Knapp 1 Sb. INFORMANT' MAMAVB ADDRESS (STREET ORRF.D. NO- CITY OR TOWN. STATE. 21P1 8 N. Howard Grand Island, NE. 68803 - SIGNATURE ✓k. _ 21,& METHOD OF DISPOSITION 21Q .DATE a CEMETERYOR CREMATORY -NAME T21 �/�/j 92 Xp Bald p R.moval Aug 13 , 2004 Rose Hill Cemetery 22& FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CRY OR 70VM1 STATE p °i""'�°' p °anatlai Palmer.: 68864 NE Curran Funeral Cha 1 22b. FUNERAL HOME ADDRESS (STREET OR'RF.D: NO- CITY OR TOWN. STATE. ZIP) 3005 South Locust Street Grand Island NE 68801 i IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UM FOR la). 1b6 AND ICII Inierod bah ear orrod and dsam PART ..., - . Alf ,I ,(el Hye�: l., ;v;. kMery ornd and death DUE Ta OR AS CONSEQUENIDE /N %OF: /} 1bl E TO. AS A CONSEQUENCE OF: I Interval arhsa and death . DU NC 'L,f. Col; �. (c) REFERRED OTHER SIGNFTCANT CONOITKN4S - GW Mau C2�nQ b the death but rrbtrNalad P ATM IF FEMALE WAS THERE A 24. AUTOPSY 25. WWAS CA E OR CORONER? PART PREGNANCY IN THE PAST 3 MONTHS? a" - (Ages 10 -541- Yes NO Yea No Yes No 28& Mb. DATE OF INJURY W Dry• Yr) 28a HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Aceded UrhdelarmWSd 'M 28e. INJURY AT WORK 1t • lem. street hCCry . 28L P IKE QF M ARV A. 284 LOCATION STREET OR RF.D. NO. CITY OR TOWN STATE Srddds Pehhdtrr9 0 Homicide Wv00igma- Yes O No p ( DATE OF DEATH (Ma Day. Yr.) 28& DATE SIGNED (M- Gay. W..) 28b. TIME OF DEATH ...M S�3 IJ f 6 y jv Ae. DATE BONED [Al. Dq• Yrl nME of DEATH `� 28a PRONOUNCED DEAD /Afa Gry. Yr -) 28d. PRONOUNCED DEAD /Fburl 'any y �$$$. /�i /� / M M E / ✓r� To the beet d my tawladge. death accurral at tm0. data and place and due to the 3 / v a 28e. On are Dash a d once an dus to hvestigallm calea(s) t my oPl^pn death occurred at the Nme. dale and place and due b the causMsl dried. . cat -e(sl alelad. L1 J - -1 H and ISignaitre mW TM91 No DID TOBACCO USE CONTRNiLLSE TO THE DEATH? `-w HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? WAS CONSENT GRANTED? . p YES p NO YES NO p YE S 40 UNKNOWN 31. NAME AND ADDRESS OF CERTFIER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type ar Pmt) . Jeffrey K. King M.D. 729 N. ster AV G4dnd Island NE 68803 32a _ Da DATE F1LED BY REGISTRAR pto., Day Yr.) 13M AUG 18 2004 v