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<br />WHEN TM COPY CARRES TIE RAISED SEAL OF THE NEBRASKA I/WIVAIYD HVMAN-SERNCES
<br />SYSTEM IT CERTFES TIE BELOW TO BE A TRUE COPY OF THE 640 AL REC0q&OHFJEE -WTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SSTI("EGMA, ITCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />E.
<br />DATE OF ISSUANCE 200304096 °.,
<br />Iiki
<br />r ' i i � IiLE'Y 4- CUOft"
<br />FEB 220� Ass18�11 - sTAfeAEOISTRAR
<br />LINCOL), J'al . _ HEALTHA! '6HU6b A SERYICESAYS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMA14 SERViCESATIANC£�d�l1PP�RT ^'
<br />VITAL STATISTICS _ 0 3 0 14 3 6
<br />CFRTTFiCATF OF DEATH =
<br />I . DECEDENT -NAME FIRST MIDDLE LAST
<br />Z SEX.
<br />J. DATE OF DEATH /Month Dar Year;
<br />William Fredrick Opp
<br />Male
<br />February 3, 2003
<br />4. CITY AND STATE OF BIRTH 1/I not h USA.. name coumryl
<br />5a. AGE ' Last Birthday
<br />p 3
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMonlh. Dav Year/
<br />Mos. DAYS
<br />sd.HOQRS MINS.
<br />Grand Island, Nebraska
<br />'Yrsl 58 5b
<br />y
<br />7, SOCIAL SECURTIY NUMBER
<br />Fir
<br />505 -54 -4220
<br />z
<br />n
<br />i
<br />C
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />o 0
<br />0
<br />n
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Wood River
<br />M
<br />>
<br />11. ANCESTRY leg. Italian. Mexican. German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /ft wife. give maiden name)
<br />e1c.I(Specify) White
<br />(Specify) German
<br />NEVER DIVORCED
<br />M 1
<br />Patricia Shotkoski
<br />n
<br />7C
<br />X
<br />S
<br />15. EDUCATION )Specify only highest grade completed)
<br />p
<br />o
<br />T
<br />16. FATHER -NAME FIRST MIDDLE LAST / 7.
<br />vM
<br />oN
<br />Lorena Heinrich
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. na prruunk.) (If yes. give war and dales of services)
<br />m
<br />0
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. ZIP)
<br />1110 West St., Wood River, NE. 68883
<br />r D
<br />-�L
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME -
<br />`%�
<br />���°f ,j, (,( LIU.11:,�'01ZV
<br />❑Bodal ❑Removal
<br />Feb. 6, 2003 Central
<br />Nebraska Cremation
<br />22a. FUNERAL HOME - NAME
<br />GO
<br />Apfel Funeral Home
<br />©Cremation F] Donation
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS [STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />411 West 11th St., Wood River NE 68883
<br />23. IMMEDIATE CAUSE ]TER ONLY ONE CAUSE PER LINE FOR lal. (b). AN p Interval between onset and seam
<br />qy PART 1 , ( O �
<br />N
<br />D
<br />CD CD
<br />DUE 70.OR AS A CONSEQUENCE OF: - Interfal between onset and death
<br />I
<br />(c)
<br />OTHER SIGNIFf
<br />PART
<br />NT CONDITIO S - Conditions contributing to the death but not related PART
<br />PREGNANCY
<br />III IF FEMALE. WAS THERE A 24
<br />IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />If
<br />=
<br />(Ages
<br />10 -54) Yes No
<br />Co
<br />U)
<br />of
<br />v
<br />NO EIRN
<br />WHEN TM COPY CARRES TIE RAISED SEAL OF THE NEBRASKA I/WIVAIYD HVMAN-SERNCES
<br />SYSTEM IT CERTFES TIE BELOW TO BE A TRUE COPY OF THE 640 AL REC0q&OHFJEE -WTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SSTI("EGMA, ITCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />E.
<br />DATE OF ISSUANCE 200304096 °.,
<br />Iiki
<br />r ' i i � IiLE'Y 4- CUOft"
<br />FEB 220� Ass18�11 - sTAfeAEOISTRAR
<br />LINCOL), J'al . _ HEALTHA! '6HU6b A SERYICESAYS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMA14 SERViCESATIANC£�d�l1PP�RT ^'
<br />VITAL STATISTICS _ 0 3 0 14 3 6
<br />CFRTTFiCATF OF DEATH =
<br />I . DECEDENT -NAME FIRST MIDDLE LAST
<br />Z SEX.
<br />J. DATE OF DEATH /Month Dar Year;
<br />William Fredrick Opp
<br />Male
<br />February 3, 2003
<br />4. CITY AND STATE OF BIRTH 1/I not h USA.. name coumryl
<br />5a. AGE ' Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMonlh. Dav Year/
<br />Mos. DAYS
<br />sd.HOQRS MINS.
<br />Grand Island, Nebraska
<br />'Yrsl 58 5b
<br />February 1, 1945
<br />7, SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -54 -4220
<br />HOSPITAL O Inpatient OTHER_ ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name pfnot institution° give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specdv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />yi_ [a No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Wood River
<br />1110 West St. 68883 Yes[ No ❑
<br />10. RACE - (e.g., White, Black. American Indian,
<br />11. ANCESTRY leg. Italian. Mexican. German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /ft wife. give maiden name)
<br />e1c.I(Specify) White
<br />(Specify) German
<br />NEVER DIVORCED
<br />M 1
<br />Patricia Shotkoski
<br />14a USUAL OCCUPATION tGwe kindot work done durafy most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION )Specify only highest grade completed)
<br />Elementary o ondary 10 -12) College T -4 or 5 • I
<br />of working file, even if retired)
<br />Business Owner
<br />Bar /Tavern
<br />16. FATHER -NAME FIRST MIDDLE LAST / 7.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William Opp
<br />Lorena Heinrich
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. na prruunk.) (If yes. give war and dales of services)
<br />Patricia Opp
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. ZIP)
<br />1110 West St., Wood River, NE. 68883
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME -
<br />`%�
<br />���°f ,j, (,( LIU.11:,�'01ZV
<br />❑Bodal ❑Removal
<br />Feb. 6, 2003 Central
<br />Nebraska Cremation
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />©Cremation F] Donation
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS [STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />411 West 11th St., Wood River NE 68883
<br />23. IMMEDIATE CAUSE ]TER ONLY ONE CAUSE PER LINE FOR lal. (b). AN p Interval between onset and seam
<br />qy PART 1 , ( O �
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />DUE 70.OR AS A CONSEQUENCE OF: - Interfal between onset and death
<br />I
<br />(c)
<br />OTHER SIGNIFf
<br />PART
<br />NT CONDITIO S - Conditions contributing to the death but not related PART
<br />PREGNANCY
<br />III IF FEMALE. WAS THERE A 24
<br />IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />If
<br />�S Oh�c 1Y\� 1 �w �� ���
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a. 11
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLLApCEE OF, INJURY - At to , farm. street. factory
<br />oeice bolding. etc. (Specify(
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑Norrlicide Investigation
<br />No[:]
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr .I
<br />28b. TIME OF DEATH
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day. Yc1
<br />28d. PRONOUNCED DEAD (Hour)
<br />i
<br />>V }
<br />1oY�aY� 5 2�3
<br />X5:40 PM
<br />_
<br />M
<br />27d. To the best of my knowledge occuved at t Time, tlate d
<br />place and due to the
<br />28e. On the basis of examination and-or investigation, in my opinion death occurred at
<br />2
<br />r-
<br />a
<br />cauwlsl stated. -
<br />0
<br />Me time, date and place and due to the cause(s) stated.
<br />ISi nature and Title) ►
<br />-
<br />IS nature and Title
<br />29, DID TOOBBAICCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />W YES ❑ NO ❑ UNKNOWN
<br />"'D
<br />❑ YES ® NO
<br />❑ YES ® NO
<br />31, NAME ANANN ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY (Type or Piino
<br />Steven Husen M.D. 2116 W. Faidley Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (MO.. Day Yr)
<br />FEB 112003
<br />it V
<br />
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