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I <br />H <br />a <br />o <br />d <br />o <br />o <br />H v <br />11yCC <br />P4 <br />ra _ >; <br />m CA A <br />Z n = m <br />_ 1 t <br />a � <br />u� <br />_ n, cn <br />_.. o --+ O <br />o C D N N <br />Z <br />r7 O <br />N q n O <br />I <br />x m <br />r O ,N1. <br />CD <br />� N <br />N a <br />� f1-i rj. <br />Cn <br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM R CERTFWS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL, E WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIH /S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE §` <br />10/14/2004 200410275 AS €ANRS <br />LINCOLN, NEBRASKA HEALTH AAdN ` SE ' <br />5 -_ <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAM $ER#i SRT <br />VITAL STATISTICS - -0 4 11010 <br />CERTIFICATE OF DEATH <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX - - <br />3. DATE OF DEATH /Month. Day. Year/ <br />Shirley Ann Hoffa <br />Female <br />I October 5 2004 <br />4. CITY AND STATE OF BIRTH /f/not kt USA., name couriby) - <br />Sa. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Mont. Day. Year) <br />MOS. l DAYS <br />5c. HOURS MINS. <br />Grand Island, Nebraska <br />(Yrs.) 76 Sb. <br />September 24, 1928 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />508 -28 -8871 <br />HOSPfTALL ❑ Inpatient OTHER: ® Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name (If not inshilution, give strife/ and number) <br />Wedgewood Care Center <br />❑ DOA ❑ Other(Specr/vr <br />8c CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes © No ❑ <br />Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zip Code / <br />9e. INSIDE CITY LIMBS <br />Nebraska <br />Hall <br />Grand Island <br />604 W. 11th St. 68801 <br />Yes ®Nd ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian, Mexican, German, MI <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (If wife. give maiden name) <br />etc.) (Specify) White <br />W11 <br />(Specify( American <br />NEVER DIVORCED <br />MAR <br />Robert W. Hoffa <br />14a. USUAL OCCUPATION /Give kind of work done during most 14D. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of work kfe, even dreared/ <br />I omemaker <br />Domestic <br />or onda 111 21 .... - College (1 -4 or 5-1 <br />°ja i Syr <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Frank Ladwig <br />Lillian M. Slonsk <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a, INFORMANT -NAME <br />(Yes. no. or unk.) (If yes. give war and dates of services) <br />No ---- - - - - -- <br />Robert W. "Bob" Hoffa <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CRY OR TOWN. STATE. ZIP) <br />6 11th St., Grand Island, Nebraska 68801 <br />20. E MER - SIGNA UR ICE 0. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY NAME <br />J <br />K]Burial ❑Removal <br />Oct. 9, 2004 <br />Westlawn Memorial Park <br />22a. FUNERAL ME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin stop- Sondermann F.H. <br />❑Cr8m8h0n ❑Donaw <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b), AND (c)) Interval between onset and death <br />PA RT <br />\ <br />(al TT�7i 1 <br />DUE TO(,, OR AS A CO1NSiEO . I Inerval between onset and death <br />J� <br />/F Iw'"HN �i^'►.(.JS'L �.ii� '�'ri^�C'1PL!' <br />(b) 1 [� <br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death <br />_ I <br />Icl I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART <br />PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />11 CD �� PREGNANCY <br />IN THE PAST 3 MONTHS? -4-- <br />/,EXAMINER OR CORONER? _ <br />A <br />(Ages <br />10 -541 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 INJJRY OCCURRED <br />❑ Accident F] Undetermined <br />M <br />❑ Suicide ❑ Pending <br />26e. INJURY AT WORK <br />26f. PLAB 6wMi IN U Y /SAt Iw,r1tF, farm. street. factory <br />offfifi h PBCaY/ <br />26g. LOCATION STREET OR R.F.D. N0. CITY oR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />27a. DATE OF DEATH (MO.. Day. Yr.) <br />28a. DATE SIGNED (W... Day. Yr.) <br />28b. TIME OF DEATH <br />October 5, 2004 <br />E <br />M <br />$ '0 <br />a <br />� <br />i <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Hour/ <br />=O <br />11:35 A.M. M <br />a � � <br />27d. To the best of my knowledge. death occurred at the time, dale and place and due to the <br />289. On the basis of examination and,or investigation, in my opinion death occurred at <br />k causels) stated //j1/� /y����/ r� <br />v E <br />the time, date and place and due to the cause(s) stated. <br />Ioll(Signature <br />(Signature and Title) ji, <br />and TNe ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? ��g�" <br />X" ❑ YES NO ❑ UNKNOWN <br />❑ YES NO ,r <br />❑ YES ,I /I� NO <br />7"� <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdntl <br />Dr. Anne Mo se, M.D., 72,9 N. Custer, Grand Island, NE 68803 <br />32a. REGISTRAR - <br />32b. DATE FILED BY REGISTTTRAR (Mo.. Day. Yr' <br />11 • <br />