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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATEDEPARTNaff - CPAT."TH, <br />IT CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD ON FILEWNffH ff#ESTATE <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE_LfdAL- D_ EPOSIT_ORY FOR. <br />V ?AL RECORDS. = _ <br />= _ <br />DATE OF ISSUANCE 200305137 = _ <br />SEP 2 8 1994 STANLEY S. COOPER Dfi?ECTOg <br />_ LINCOLN,. NEBRASKA BUREAU OF VITAL- 5TA7 /ST /E� <br />STATE OF NEBRASKA - DEPARTMENT OF HEALS 7. = - <br />BUREAU OF VITAL STATISTICS i '- <br />CERTIFICATE OF DEATH -, _ <br />4C ) <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month Oak Year) <br />Gerald <br />6. CITY AND STATE OF BIRTH /a.roln U.S.A.. name counay/ <br />5a. GE - Last Birthday <br />UNDER 1 YEAR <br />UNDER t DAY <br />6. OATE OF BIRTH /Moro. Day Year) <br />MOS DAYS <br />5c. HOURS' MANS <br />Greeley, Nebraska <br />(YrsI 5b <br />71 <br />Eebimar!y 9, 1923 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />HOSPITAL � ❑ Inpeeert OTHER. ❑ Nwasi g Home <br />® ER O ❑ Residence •. <br />8b. FACILITY - Name Ill not mist" gme seat and marr 1 <br />St. Francis Medical Center <br />❑ DOA ❑ Dow(SpecMl <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />nd INSIDE CITY LIMBS <br />Be. COUNTY OF DEATH <br />wen W No ❑ <br />Hall <br />9s. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (iricl dig Zp Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />rand Isl nd <br />1303 E. 16th <br />Yes "° ❑ <br />10. RACE - le¢, What. Black. American Indn, <br />11. ANCESTRY iiii Malin. Mexican. German, fac) 12. ®MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /h wwM 9rve rrMden name/ <br />eb.IfSpsdyl <br />White <br />ISpecMl NEVER DIVORCED <br />I American n b MARRIED <br />Ursula E. Piontek <br />16a. USUAL OCCUPATION /Give tndo( work dare dta►tg ntoaf ibb. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only "hest Wade conpbbd) <br />d novkng NMA pen it mow) <br />Journeyman Printer <br />Newspaper t`�� <br />Ebnfsmary 10 -t21 It -�a5•I <br />il`°b'r' 1°"°°e <br />16. FATHER -NAME FIRST MIDDLE UST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Jess R. Gillham I <br />Ruby Marie Kelley <br />18 WAS DECEASED <br />EVER IN US. ARMED FORCES? <br />t9a. IIFOFWMNT - NAME <br />(Yes no. of utc) <br />IM yes. give war and dates d esrviceal <br />Yes; <br />5 -13-43 3 -1 -46 <br />19b. INFORMANT MAILING ADDRESS (STREET OR RFD NO., CRY OR TOWN. STATE ZIP) <br />303-E 16th Grand Island, <br />20.E - SIGNATUR lJC y <br />21 S METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORYNAME <br />aiz <br />®Ronal ❑ Rendval <br />Se t. 26, 199 <br />Westlawn Memorial Park <br />- N <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />❑ Dw""° Donation <br />f 1 -B er <br />Grand Island, Nebraska <br />22b. UN SS (STREET OR RF.D. NO.. CITY OR TOWN. STATE ZIP( <br />1123 West Second Street Crand Tsdand, Nphraska 68801-58c)(C) <br />23. IAMwED1A CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. (b), AND (c)) Imeval between onset and death <br />PART I <br />I(a) I Ck <br />DUET I. CON ENCE OF Irlerval between Offset and death <br />I <br />MI P i C !'ems <br />DUE TO. OR AS A CONSEOUENQE OF Interval between onset and death <br />I <br />PART OTHER SIGNIFICANT CONDITIONS - ConOaons consibWV to ere death boa not rebbd PART <br />III IF FEMALE. WAS THERE A <br />.WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />IN THE PAST 3 MONTHS( <br />7AU�OPSY <br />EXAMINER OR CORONER' <br />(Ages <br />10 -56) Yes NO <br />No <br />El <br />Yes NO <br />26a. <br />26b. DATE OF INJURY /Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />260. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident ❑ Undetermined <br />M <br />❑ Sw ide ❑ Pending <br />Me. INJURY AT WORK <br />261. PLACEdnQFF IINN,JeUroRY ;[d hprwe/ ,Farm. street. factory <br />d66ccee �Pecq' <br />26g. LOCATION STREET OR R D NO. CITY OR TOWN STATE <br />❑ FlOrftrJOe Investigation <br />Yes ❑ Np ❑ <br />1 <br />27a DATE OF TH / Day YL) <br />28a DATE SIGNED (Mo. Day. Yr.) <br />28b TIME OF DEATH <br />M <br />27b DATry SIG DN /MO.. y. Y) <br />27c. TIME OF DEATH <br />2& PRONOUNCED DEAD (Mo. Day, Yil <br />260. PRONOUNCED DEAD /HOUrI <br />$ g <br />%E <br />! <br />M <br />M <br />i <br />° <br />°u <br />270 To ene t>� d my knowledge. de curr fkne, tlab and place and due ro the <br />To the b <br />28e. On Ire basis d examination and-o in opinion death occwered at <br />stated ` <br />/•"AiJI \� <br />tlfs nme, dab and place and due ro the causelsl <br />( and Tab <br />and Tree <br />29. DID TOBACCO USE CONTRIBUTE T E DEAT 30.a <br />HAS ORGAN OR TISSUE DONATION ,B�EEN/�N SIOEREDI 30.b <br />WAS CONSENT GRANTED' <br />❑ YES ❑ NO UNKNOWN <br />❑ YES U "" <br />❑ YES ❑ NO <br />31. NAME AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) !Type or Prea) <br />Dr. William C. H de, 2620 W. Faidley Avenue, Grand Island, Nebraska 68802 <br />32a REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Ab. Day. Y.) <br />SEP 28 1994 . <br />d <br />