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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPAffMpYT,SFNMLTH, ? CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD 6VfMf__ 69ITh_TMr=A7E DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS TIC_ LEA_ e4_ Z; VffAL RECORDS. _T ATE OF ISSUANCE D 200411801 =-_= -- �- STA �3^ CALEB MAR 19 1997 LINCOLN, NEBRASKA NESRAS"A¢� 41111�M19F f HEALTH STATE OF NEBRASKA - DEPARTMENT OF_f44AETW - -, BUREAU OF VITAL STATISTICS - - CERTIFICATE OF DEATH 1 DECEDENT -NAME FIRST MIDDLE LAST 2. SEX , 3. DATE OF DEATH /Month. Day ✓earl Frances Lucille Adams Female March 8 1.997 4. CITY AND STATE OF BIRTH (Mnof In USA., name country) 5a. AGE - Last &nhoay 1 YEA UNDER R UNDER 1 DAY 6. DATE OF BIRTH (MOrtet. Day year) 5b. MOS. DAYS 5c. HOURS MINS. 26b. DATE OF INJURY /MO. Day. Yr.) IYrs.l February 21, 1917 Ashton, Nebraska 80 M 7. SOCIAL SECURTIY NUMBER . 8a. PLACE OF DEATH HOSPITAL: Inpatient OTHER Nursing Home 508 -18 -8210 -- - ER Outpatient Res"dence 8b FACILITY - Name (M not rnstiNtron, give 51ree1 and numoerl DOA Other (Specityl St. Francis Medical Center fic. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island YB5 0 No [-] Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1927 W. 13th St. 68803 1 VeSfR No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le.g.. Mogan. Mexican. German, atc) 2.:U MARRIED ❑ WIDOWED 13. NAME OF SPOUSE pt wde give msiden name) etc.) ISDecily) White Polish NEVER DIVORCED 1 Dorsey Adams 14a. USUAL OCCUPATION (Give kindof iii done during most 14b. KIND OF BUSINESS INDUSTRY \ 15. EDUCATION (Specify only highest grade completed) of nolktng lee, even Areeied) ENmenany a Secondary 10 -12) College 11 4 or 5•I Owner/Operator Ceramic shop 6th Grade 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Tom NMI Ward n (Dec.) Anna NMI Persak -Dec. 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 198. INFORMANT -NAME (Yes, no or unk.l pt yes. give war and dates W services) Si nature and Title No N/A I Dorse Adams 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D NO_ CITY OR TOWN. STATE. ZIP) West 13th Street, Grand Island, Nebraska 68803 ___1927 20 EM LMER - SIGNATURE b UCENS O. O /�� 21 a. METHOD OF DISPOSITION 21b. DATE 21C. CEMETERY OR CREMATORY NAME 32D. DATE FILED BY ijE l$TBeR yL1a71997 Cem �Burial Removal March 11, 1997 Westlawn Memorial Park 22a. FUNERAL HO - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Home ❑Cremation ❑Donat- Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 3213 W. North Front St., Grand Island, Nebras'a 68803 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). IN. AND Icl) Interval between onset and death ART / I (al A -C_o -�_ I ✓LAPcti�6/ -1- DUE TO, OR AS A CONSEQUENCE OF, Interval between onset and death h �Li.�,:lr.L, Ck ICI , in,. Ivtween onset and death iuue I u. un na n i,unaewu..,e yr/ <T. n.In,0 �Troe,.e i�li3Tret( rI�, �fv+ teary .0,1PaS'1) uny j °�i:'1 OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A AUTOPSY 7f' VJAS CA REF RRED 70 MEDICAL �i EXAMINER OR CORONER' PART PREGNANCY IN THE PAST 3 MONTHS? II _ ��Q �L1C i(Ages 10 -54) Yes o Yes No Yes No 26a 26b. DATE OF INJURY /MO. Day. Yr.) 26C. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined M _ Suicide Pending 26e. INJURY AT WORK 261. :E OF INJ�UtRY - Atthhome. )arm. street. factory 26g. LOCATION STREET OR R F.D NO CITY OR TOWN STATE � ❑ O6 otl Homicide Investigation Yes No 2 DATE OF DEATH (Mo. Day Yri 28a. DATE SIGNED (MO. Day Yrt 28b TIME OF DEATH M = b DATE SIGNED (Mo. Daajy.I�Yr i) �c. TIME OF DEAATTH $p€ ` 28c PRONOUNCED DEAD (Mo. Day. Yr 28d. PRONOUNCED DEAD IHOUrI t (/�� o �'� (,� rl M • cS ¢ M . ~ To the best of my knowledge. de occurred at the time. data and place and due to the 8 u 280. On the basis of examination and, or investigation . n my opimon death occurred at < cause(s) stated. I o a Me time. date and place and due to the causelsl stated. 0. ,(/J µ.. _ %- U � ( � (Si nature and Title Si nature and Title DID TOOBBACCO USE CONTRIBUTE TO TH DEATH? .a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' WAS CONSENT GRANTED? �!. IN YES � NO 0 UNKNOWN ® -N ***D YES R NO E] YES R1 NO 31. NAME AN ADDRESS OF CERTIFIER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) James L. Omel MD, 2116 W. Fa'dley Ste 40 Grand Island, NE 68803 32a. REGISTRAR 2�" (Aot 32D. DATE FILED BY ijE l$TBeR yL1a71997 Gv at