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WHEN Tim COPY CARRIES!ne RAISED SEAL OF THE NEBRASKA W.ALTH AND HUMAN SERWCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON F E-ADW -
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECioN,:
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />FEB p
<br />2 5 z000 200410955
<br />ASSISTANT STATE
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN 9*#WCE$,SYSTEM t
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTtl
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DFATH - -
<br />t. DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />M
<br />M
<br />f)
<br />_
<br />Davis
<br />Female
<br />February 6, 2000
<br />4. CITY AND STATE OF BIRTH / lWo USA.. name counlgq
<br />Sa. AGE -Last Birthday
<br />C
<br />z
<br />M y
<br />_
<br />6. DATE OF BIRTH /Mor1'r. Day Year/
<br />o
<br />d -4
<br />o �'
<br />Palmer, 'Nebraska
<br />vr'I 78
<br />O
<br />tJCl..C1lU.JC ,
<br />LJCceffbex 23 1921
<br />I7. SOCIAL.,$IECURTIY NUMBER �
<br />8a. PLACE OF DEATH
<br />501,-24-'4947
<br />HOSPITAL
<br />-__-
<br />® Inpatient OTHER E] Nursing Home
<br />El ER Oupattent Residence
<br />8b. FACILITY - Name /a not nsfihaitxn, give sheaf and number)
<br />St. Francis Medical Center
<br />C=
<br />CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® Nd ❑
<br />Hall
<br />9a. RESIDENCE - STATE 9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER prrogrdag Zp Code/ 9e INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />in
<br />o ��
<br />10. RACE - ,e.g., White. Black. American Indian. 11. ANCESTRY leg.. Italian. Mexican, German, etc/ 12. ®MARRIED
<br />° "T1
<br />etc.I (S11eaNl ,Specify,
<br />White American NEVER
<br />MAR
<br />DIVORCED Otis A. Davis
<br />D
<br />14a, USUAL OCCUPATION /Glue kmdol rack done during rihc6't'
<br />o/-&*I r,gkk even d refired/ 1
<br />T4b KIND OF BUSINESS INDUSTRY
<br />- _
<br />O
<br />-YT -
<br />CD
<br />-'M
<br />-_
<br />-
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST 17. MOTHER
<br />FIRST � MIDDLE MAIDEN SURNAME
<br />c/
<br />Aleda NMI Anderson,
<br />n
<br />�a
<br />(Yes. no. or unk.l I III yes. give war and dates of services) )
<br />M1
<br />�
<br />:3
<br />r
<br />r v
<br />o
<br />cD
<br />ry
<br />cn
<br />Z
<br />0
<br />WHEN Tim COPY CARRIES!ne RAISED SEAL OF THE NEBRASKA W.ALTH AND HUMAN SERWCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON F E-ADW -
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECioN,:
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />FEB p
<br />2 5 z000 200410955
<br />ASSISTANT STATE
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN 9*#WCE$,SYSTEM t
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTtl
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DFATH - -
<br />t. DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Dorothy Helen
<br />Davis
<br />Female
<br />February 6, 2000
<br />4. CITY AND STATE OF BIRTH / lWo USA.. name counlgq
<br />Sa. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mor1'r. Day Year/
<br />Sb MOS
<br />DAYS
<br />5c. HOURS MANS
<br />Palmer, 'Nebraska
<br />vr'I 78
<br />O
<br />tJCl..C1lU.JC ,
<br />LJCceffbex 23 1921
<br />I7. SOCIAL.,$IECURTIY NUMBER �
<br />8a. PLACE OF DEATH
<br />501,-24-'4947
<br />HOSPITAL
<br />-__-
<br />® Inpatient OTHER E] Nursing Home
<br />El ER Oupattent Residence
<br />8b. FACILITY - Name /a not nsfihaitxn, give sheaf and number)
<br />St. Francis Medical Center
<br />DOA ❑ other /Spec,tyl
<br />CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® Nd ❑
<br />Hall
<br />9a. RESIDENCE - STATE 9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER prrogrdag Zp Code/ 9e INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />610 West 9th St., 68801 Ye' ® No
<br />10. RACE - ,e.g., White. Black. American Indian. 11. ANCESTRY leg.. Italian. Mexican, German, etc/ 12. ®MARRIED
<br />❑WIDOWED 13. NAME OF SPOUSE /a rrk. give maiden name/
<br />etc.I (S11eaNl ,Specify,
<br />White American NEVER
<br />MAR
<br />DIVORCED Otis A. Davis
<br />D
<br />14a, USUAL OCCUPATION /Glue kmdol rack done during rihc6't'
<br />o/-&*I r,gkk even d refired/ 1
<br />T4b KIND OF BUSINESS INDUSTRY
<br />- _
<br />15. EDUCATION (Specify only hghesi grade completed)'
<br />E lemernary 2 or mn
<br />Serdary (0 12) College 11 -4 W 5 -I
<br />1 - -
<br />. - .j e
<br />Dmsti C,
<br />1 .. '
<br />Med 1 c.
<br />-
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST 17. MOTHER
<br />FIRST � MIDDLE MAIDEN SURNAME
<br />IYan NMI "wdley
<br />Aleda NMI Anderson,
<br />,18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.l I III yes. give war and dates of services) )
<br />Lr NO
<br />-wr.m r mArumu AUUHtbb - (STREET OR R D NO.. CITY OR TOWN. STATE. ZIP)
<br />`
<br />t I wd, Nebraska 68801
<br />2t). EMBAL ER - SIGNATURE A LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE
<br />200 CEMETERY OR CREMATORY - NAME
<br />D3 [� Buda, ❑ Removal Feb. 11 2000 Grand Island City Cemetery
<br />22a.IJNERAL HOME - NAME I 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />sine Funeral Hane El Gealabon El Donal on Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP)
<br />3213 W North Front St Grand Islam Nebraska 68803
<br />IMMEDIATE CAUSE ,ENTER ONLY ONE CAUSE PER LINE FOR lal. (b), AND (cp I
<br />PART Interval be1Nre�en onset and death
<br />L- W
<br />I. - _ ..zz.,ks
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />(b) _r
<br />Interval between onset and death
<br />I
<br />(cl
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions c ,g to the death but no related PART III IF FEMALE. WAS THERE A � AUTOPSY Wq$ CASE REFERRED TO MEOtC L
<br />PART I
<br />PREGNANCY IN THE PAST 3 MONTHS? _ E %AMINER OR CORONER
<br />[l . \� �� -�`rvJ j (Ages ID -541 Yes No Yes No Yes No
<br />26b. DATE Of INJURY /MO. Day Ynl 26c. HQUR,QF MI0URY _ vr- 26f1. DESCRIBE HOW INJURY OCCURRED
<br />- _
<br />�;
<br />Acndenl � Undetermined -.
<br />Su-C(de. Qr .Pending 26e. INJURY AT WORK', 26f. life EO 'N'UR V - , farm,'real factory 26g- LOCATKNJ STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide IlnveslgaM1On 'Yes No T
<br />7v.. DATE OF DEATH IMO. Day Yr/ / y TIME OF DEATH
<br />ti 28a DATE SIGNED Mo.. Day. n
<br />H DA7 §GNED� /Mo. Day Yrl TIME OF DEATH u g
<br />i r _f.�. y 7. _ k y 28c. PRONOUNCED DEAD (Ad Day. Yr/ 28d. PRONOUNCED DEAD /(bur) 1(♦f
<br />z
<br />M
<br />To the best M my k at ama, dafe and piece and dye ro the 28e On the base' d examination and/or imrestgaaon, in my opinion death occurred al
<br />causels) sated. g
<br />` � / � , • the time. oats and place and due to the tause,si stated.._ -
<br />2 nature and Title - `/ and Title
<br />r
<br />. DID TOBACCO USE CONYRIBUTE -TO THE DEATH? We HAS ORGAN OR TIS UE ATpN BEEN CONSIDERED?
<br />-;,... , \ _- -I, , r WAS CONSENT GRANTED?
<br />YES NO fl UNKNONiN- ' i YES 1770 .' - �. t1 -
<br />NO
<br />`31.. NAMEAND ADDRESS OF CERTIFIER (PHYSICIAN, COAONER'S PHYSICIAN OR COUNTY ATTORNEYI, /Type a, Print)
<br />Donald G. Wirth MD 6 W Fa' 140x; Grand Island, Nebraska 6$803
<br />32a. REGISTRAR _ ,r 32b. GATE FRED 8Y AE0 -
<br />FEB`9 8 two
<br />LF?`AT, DFFCP1PTT0r7- The Fasterlv Fifty 50 f
<br />cix (F) ( ) -set of I,ot reline (Q) in Floek
<br />in F. r;, Clark's Addition of Crand Island, F *all County, Nebraska
<br />c
<br />
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