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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH SYSTE14 ff CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 11/19/2003 200411911 LINCOLN, NEBRASKA HEAL it Nvf: STATE OF NEBRASKA. DEPARThEM OF HEALTH VITAL STATJS`=I rjRRTrFtrATP aw '03 2 9 0 3 1. DECEDENT -NAME FIRST MIDDLE LAST 2 Sip, DATE OF DEATH jAlonth. Day. Yea/ Orville Indra Male Nov 7 2003 1 4. CITY AND STATE OF BIRTH f#rW In U.S.A_ name counsyl 5a. AGE -.last BiMftV UNDER I YEAR UNDER I DAY S. DATE OF BIRTH (ftnift Day. Yeo Mo S. DAYS Sc. HOURS' M`Ns. Clarkson, Nebraska ry-) 6b 83 1 Au g 6 1920 7. SOCIAL SECURTIY NUMBER Se. PLACE OF DEATH 505-58-5129 HOSPITAL Me /ant OTHER: Mintil Home ER!Ou0ab@nt Residence ft FACILITY - Name Saint Francis Medical Center ❑ DOA oil. 8C. CITY. TOWN OR LOCATION OF DEATH Od INSIDE CITY LIMITS go. COUNTY OF DEATH Grand Island -RESIDENCE Yea EXI NO ❑ Hall- 9Z • STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION Od STREET AND NUMBER Mc*A*WZO Code/ 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 11505 W. Newcastle Rd 68801 Yea X N. ❑ 10. RACE - (ag, White. Black. American Indian. 1, ANCESTRY (e.g.. Rallan. Mexican, German. sIcI 11 [% MARRIED, ❑ WIDOWED El 13. NAME OF.SPOUSE e1c.) (S"C'm White I (Specify) Czechoslovakian D NEVER . DIVORCED MARRIED Catherine Kirwan 14a. USUAL OCCUPATION tC4 *vdc1xvr* done d#Mmop 14b. KIND OF BUSINESS INDUSTRY 115. TION tspft* completed) only WetsiWade ElarnorSecttodarYM-12) College 11 -4 or 5•1 Soil Conservation Sci Federal Goye 1 2 6 16. FATHER -NAME FIRST MIDDLE LAST 17. -_ MOTHER FIRST MIDDLE MAIDEN SURNAME Frank Indra Katie Kunc I& WAS DECEASED EVER IN U.S. ARMED FORCES? NAME (Yes, no. or W*4 IN yes. " war and dales of Yes IWAIlil/25/1942 12/19 1945 Catherine Indra Igh INFORMANT' MAJUNG ADDRESS (STREET ORR.F D NO- CITY OR TOWN. STATE M 1505 W. Newcastle Rd Grand Island NE 68801 SIGNATURE & LICENSE.W. 21 a METHOD OF DISPOSMON 21b..DATE CEMETERY OR CREMATORY NAME 1092 ❑ Remodel Nov 11 , 2 0 0 3 Grand Island City 22a-FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Curran Funeral Chai>el 3168 W. Stolle y Park Rd. Grand Island NE 22b. FUNERAL HOME ADDRESS (MEET OR R.F.01. NO.. CITY OR TOM, STATE, ZIP( 3005 South Locust Street, Grand Island, NE 68801 *: IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). lb), AND (c)) Inorval between onset and death PART I (a) Respiratory Failure DUE TO. OR AS A CONSEOVENCE OF: lnllhval between Onset and death fbi Acute Renal Failure DUE TO, OR AS A CONSEOLIENCE OF, I IMMai hf&-. onset and 19.11, I (C) Bacterial Endocarditis I PART OTHER SIGNIFICANT CONDITIONS - Conditions cwVbAhg to the death W nd related PARTIN IF FEMALE WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL N- PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER (Ages 10-54) Yea No Yea El No [N yes F1 No EX 26a. 211b. DATE OF INJURY (No- Day. Yr.) 26,_ HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED ❑ Accident ❑ Undetermined 1 ❑ Suicide 1:1 Pending 2119. INJURY AT WORK 136=WJURY AeV farm, asset tacin 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ❑ Homicide . Investga ban yes ❑ 1261. all- 2 DATE OF DEATH fAfo- Day. Yq 28a. DATE SIGNED (lkla. Day. Yr.) 280. TIME OF DEATH November 7, 2003 M 2(b. DATE SIGNED fAAD- Day Yr] TIME OF DEATH 211c. PRONOUNCED DEAD JA&L Del; Yr.) 28d. PRONOUNCED DEAD lHoud 11-14-03 : 1205 A.M. M beat of my knowledge. let tins, dau, ar�Vwqi at�� tome 269. On doe basis of examinalim and/or investigation, in my opinion death occurred at 'i cauae(al the finke, date and piece and clue to the C&A*S) stated. and Itlej pio 1. /E [_�s and Title) ► . DID TOBACCO USE CONTRI T THE DEATH? HAS *b D WAS CONSENT GRANTED? ❑ ES UNKNOWN NO ❑ 47 ❑ YES _j NO ❑ YES NO I n I I -T1, f IYW - I-W William J. Lawton 4I.D. 729 N. Claster Ave., Grand Island, NE 68801 4 If