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MEN THIS COPYCAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANS <br />_.SYSTEM, IT cERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 000 <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTFQW <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />26611iotf AMEY SP <br />5/26/2004 ASSISTANT ftATSId <br />LINCOLN, NEBRASKA HEALTH AND HUMAN &#VJM <br />STATE OF NWRASKA DEPARTMENT OF HEALTH AM HUMAN SERVICES FINOIC09 <br />VITAL STATISTICS <br />n . <br />V_FRTFFTrATF OF T)IRATF-T <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />Z SEX <br />I DATE OF DEATH (Manes. Day Ya-) <br />Catherine Claire Indra <br />Female <br />Ma 5 2004 <br />Pff <br />5s. AGE -18111 Bintl1day <br />VITAL STATISTICS <br />n . <br />V_FRTFFTrATF OF T)IRATF-T <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />Z SEX <br />I DATE OF DEATH (Manes. Day Ya-) <br />Catherine Claire Indra <br />Female <br />Ma 5 2004 <br />14. a" AND STATE OF BIRTH (ffrW#1U.SA. name -#ft1 <br />5s. AGE -18111 Bintl1day <br />I YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH MORA Day. YeaO <br />(Yrs.) <br />I <br />DAYS <br />5C. HOURS: <br />Wayne ' Nebraska <br />84 <br />Jan 30 1920 <br />7. SOCIAL SECURTIY NUMBER <br />fle. PLACE OF DEATH <br />ElInpatient OTHER Nursing Home <br />047-20-5046 <br />ERIOU"Ient Residence <br />8b. FACILITY - Nettie f1nWff=*N1br;pv*~ and number/ <br />Beverly Healthcare Park Place <br />DOA DOW Ispeafyj <br />CITY. TOM OR LOCATION OF DEATH Sd. INSIDE CITY LIMBS 18e. COUNTY OF DEATH <br />Grand island yes pg. No Hall <br />9s. RESIDENCE - STATE <br />9b. COUNTY <br />9C. CITY. TOWN OR LOCATION <br />91 STREET AND NUMBER (hVAA*WZIP Code] <br />9 imiR my Limrrs <br />Nebraska <br />Hall <br />Grand Island <br />11505 W. Newcastle RD 6880171K <br />ft <br />Yr <br />Y No E] <br />10. RACE - (a.9, Whits Black. American Indlah. <br />I&q., Kamm. memAn, German. sic) <br />=Y <br />I r-� MARRIED. WIDOWED. <br />3. NAME OF.SpOUSE (AF *yb. pw made" mviel <br />ev-)(SpectA <br />White <br />American I <br />E] F] DIVORCED <br />I <br />14a, USUAL OCCUPATION (Gim kind olmov* dam cluningmood 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specily only higtiestgrade wrnplviscl) <br />awn or Ssoondary (0-12) College (1-4 or 5-1 <br />OfW0011kirIgAkemonthim"o <br />Teacher <br />Univers <br />2 4 <br />16. FATHER - NAME FIRST MIDDLE LAST 7 <br />mo ER FIRST MIDDLE MAIDEN SURNAME <br />Augustine John Kirwan <br />Ca Elwood <br />Catherine Claire <br />I& WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a INFORMANT - NAME <br />(Yes, no. or Wk) fit yea give war and darts of serviibeel <br />NO <br />Martin Kirwan <br />19b. INFORMANT MAILING ADDRESS (STREET OR4;LF.D. NO- CrTY OR TOWN. STATE ZIP) <br />.18645 Hatteras St. Unit 295 Tarzanal. CA 9 356 <br />SIGNATURE <br />21m, METHMOFDISPOSITIDN <br />21NDATE 2ir- <br />CEMETERY OR CREMATORY NAME <br />7 M�ER , <br />x :mm6_)092 <br />t <br />pg.. -an-- <br />May 11 2004 <br />007 <br />Grand Island City <br />PUN&IAL HOME NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Curran Funeral Chaviel <br />3168 W. Stolle y Park Rd. Grand Island NE <br />22b. FUNERAL HOW ADDRESS ISTREET OR-RFD. NO- CITY OR TOM. STATE, ZIP) <br />3005 South Locust Street, Grand Island, NE 68801 <br />IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). f*L AND (r)) Interval between onset and death <br />PART <br />I CONGESTIVE HEART FAILURE <br />!4 <br />DUE TO, OR AS A CONSEQUENCE OF., Inte"all between onset and death <br />M TYPE 2 DIABETES MELLITUS, HYFERTZNSION. <br />DUE 70.OR AS A CONEEMOUENCE.01F. In al between onset and d"h <br />OTHER SIGNIFICANT CONDITIONS - Conditions ooftbutirM to the death but not related PARTM <br />IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />(Ages <br />10-54) Yes F-1 No F] <br />Yes 1:1 No [A <br />Yes [] No [54 <br />2ft <br />29b. DATE OFINJURY (Ate.. Dry. <br />HOUR OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />n A.W. Fj Undetermined <br />12" <br />M <br />Suicide E] Pending <br />26e. INJURY AT WORK <br />1281. PLACED gRY AV, truth. street, *1ory <br />28g. LOCATION STREET OR FLF.D. NO. CITY OR TOWN STATE <br />D Honved, , imemligallion <br />. Y. N. <br />. r <br />2PL DATE OFDEATH (Ate.. Day. Yf) <br />28a. DATE SIGNED tW Day. Yr.) <br />28b. TIME OF DEATH <br />May 5, 2004 <br />All <br />DATE SIGNED (Ate.. Day Yr) <br />TIME OF DEATH <br />28r_ PRONOUNCED DEAD /Ma. Day, Yr./ <br />28d. PRONOUNCED DEAD fHour) <br />106 <br />May 14, 2004 <br />y <br />1., 2:42 A <br />1/1 M <br />M <br />s I <br />b" 01 f"Y W...dW&r a, to 1110110. &,it due �t#_ <br />7z� <br />Me. On Me basis d timmnation andfor Irmestigation, in ffry opinion death o=ffad at <br />the time times and place and due ID dis causes) stated. <br />�2 <br />9 . <br />(Signature and T" ► = <br />fsolawe,ww TWI ► <br />DID TOBACCO USE CONTRIBTSO,TIHEDEATH?- 3t <br />I <br />11bk HAS ORGAN OR TISSUE DONATION BEEV_ONtSlDERED9 <br />-] <br />3 <br />'01b WAS CONSENT OR ANTED? <br />YES NO El UNKNOWN" <br />YES <br />[_ -S Ef <br />NO <br />YES <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type orprano <br />William J. Lawton M.D. 729 Custer Avq(4, Grand Island, NE 68801 <br />32a. REGISTRAR <br />A. <br />Vb. DATE FILED BY REGIS ISTFIAR ft. DS Y'r �004 <br />AY 2 <br />)44-94, <br />V <br />v <br />.1 <br />It <br />