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WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGO1W ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TISIWS ET ft WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 6/28/2004 00412355 HAWS COWER 2 ISrITi1liQR9TRIAR LINCOLN, NEBRASKA HEALTH AM /ALN_ SYSMM 4 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN Sffit�r4S� Ai1H-S_I FPORT rFATT�ASTF nr nFATW - 04 069 2 t. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX - 3. DATE OF DEATH tMonM. Day. Year/ Vernice Leola Zachry Female June 20, 2004 4. CITY AND STATE OF BIRTH lilt not in U.S.A.. name country) Sa. AGE - Last Birthday I UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monts. Day. Year/ MOS. i DAYS So. HOURS' MINS. Athol, Kansas (Yrs.) 82 5b. August 26, 1921 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH HOSPITAL: Inpatient OTHER: R Nursing Home 506 -18 -6748 ER Outpatient Residence 8b. FACIUTY -Name /Nnot msMution, give steel and lumberl 4039 Scheel Dr. ❑ DOA other /Speutw 8c, CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes ® No Hall 9a. RESIDENCE - STATE 9b. COUNTY gc. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code) 9e. INSIDE CITY LIMITS. Nebraska Hall Grand Island 14039 Sdbeel Dr. 68801 Yes ® No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. ❑ MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /I/ wits. give maiden name/ etc) (specify, White ISpeodyl American NEVER X DIVORCED MAR 141. USUAL OCCUPATION (Give kind of work done during moss - 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working life, even it refired) Elementary or Secondary 10 -12) College 11 -4 or 5�1 Bookkeeper Corporate 16, FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME John Maul., Edith Ball 18, WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.( (If yes. give war and dales of services) Don Zachr 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) P.O. Box 281, North Platte, Nebraska 69103 -0281 20. E B MER -S U LICE A O. 21 a METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME r #1071 X]Bedal ❑Removal June 25,2Q04Westlawn Cemetery 22a. FUNERAL HOME - NAME I 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All Faiths Funeral Home ❑Cremation ❑Donatan Grand Islands Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) - 2929 S. Locust St,, Grand Island,. Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. (bl, AND (c)1 Interval between onset and death I PARialNATURAL CAUSES UNKNOWN DUE TO, OR AS A CONSEQUENCE OF 1 Interval between onset and death I fb) DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death I I (q I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 81 IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? PART PREGNANCY IN THE PAST 3 MONTHS? II (Ages 10 -541 Yes No Yes No X Yes ® No 26a. 26b. DATE OF INJURY /Moss Day. Yr) 26c. HOUR Of INJURY 26d. DESCRIBE HOW INjjRY OCCURRED ❑ Accident Undetermined M ❑ Suicide Pending 26e. INJURY AT WORK 2". , farm, street. factory e b OfdF, INJURY-( AS 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE o(fi of6 ) ❑ Homicide Investigation Yes El No 1:1 27a. DATE OF DEATH /Mo.. Day. Yr) 28a. DATE SIGNED /Mo.. Day. Yr) 28b. TIME OF DEATH 10:00 P r ��s ^ . -c M d " 27b. DATE SIGNED /Ma.. Day. Yr) 27c. TIME OF DEATH i r 28c. PRONOUNCED DEAD /Moss Day. Yr) 28d. PRONOUNCED DEAD /Hour) s� 6 -21 -2004 12:57 A M M gg a 27d. To the bast of my knowledge, death occurred at the time, date and pace and due to the � 28e. On the basis of examination antl,or Investigation, in my opinion death occurred at ~ u ° the time. date and place and due to the causes) stated. cause(s) stated. (Si nature and Tile) ► (Si nature and Title) ► , 29k3l. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES NO ® UNKNOWN YES ® NO YES NO N AME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) SGT. COLLINS, az. bM ISLAND POLICE DEP 131 S. LOCUST ST, GRAND ISLAM, NE 68801 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /MO.. Day. Yr.) JUN 2 5 2004 !/ I