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I <br />M <br />L." <br />r <br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA b AL � SERVICES <br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE _ft Q_ F/LE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ' /Q131; W41CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />2 0 0 3 0 6 9 0 <br />APR 112003 -- �lfILS08PER <br />AWAIAAFT,ST WDISTRAR <br />LINCOLN, NEBRASKA HEA4,7?!„ AA*M _%E CS SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND EIURYIIIt4TIfiICI i(ND SUPPORT <br />VITAL STATISTICS - - 0 3 03999 <br />CERTIFICATE OF DEA I I = y <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2; SEX <br />3. DATE OF DEATH /Monty. Day. Y"i <br />Ronald Elmer Mead <br />Male I <br />Aril 2 2003 <br />4. CITY AND STATE OF BIRTH yff not in U.S.A.. name country) <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Monts. Day. Year) <br />MOS. DAYS <br />Sc. HOURS MINS <br />Wood River Nebraska <br />(Yrs) 94 Sb <br />January 20 1909 <br />7. SOCIAL SECURTIY NUMBER <br />507-16-5417 <br />8a. PLACE OF DEATH <br />- HOSPITAL: F� Inpatient OTHER: n Nursing Home <br />ER Outpatient © Residence - <br />8b. FACILITY - Name tiff not instiuson. give street and number) <br />I Western Hall Co. Good Sam. Center <br />❑ DOA Other(Specdy/ <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Wood River <br />Yes ® N. ❑ <br />Hall <br />9a. RE5IDENCE - STATE <br />90. COUNTY - <br />T -0c. C414. TOWN CS LOCATION �-. -.. _12d. <br />STREET AND NULIBER (Inch.dhngZjpCodei, _. , <br />9e. INSIDE CITY LIMITS, <br />Nebraska <br />Hall <br />Wood River <br />603 East St. 68883 <br />Yes ES No <br />10. RACE - (e.g.. While. Black, American Indian, <br />11. ANCESTRY (e.g.. Italian, Mexican, German, etcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE tiff wile. give maiden name) <br />etc) (Specify <br />t to <br />(Specify <br />'German <br />I <br />NEVER DI�l <br />EIMARRIED VORCED <br />Gladys Roberts <br />14a. USUAL OCCUPATION (Give kind of work done durng moss 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elementary o econdary (0 -12) College 11 -4 or 5.1 <br />of working life. even of rehred) <br />Owner <br />Blacksmith shop <br />16. FATHER - NAME FIRST MIDDLE LAST 17, <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Charles N. Mead <br />Kathryn Sheeks <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />[Yes. no. or unk.) (If yes. give war and dates of services) <br />No <br />Charles Mead <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE. ZIPI <br />603 East Street Wood River NE 68883 <br />20. EM ALMER - SI NATURE CENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE <br />c. CEMETERY OR CREMATORY - NAME <br />Burial EIRemoval <br />121 <br />4/5 03 <br />Wood River Cemetery <br />22s. 11i HOME - NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel Funeral Home <br />° ""�"° D°°N° <br />Wood River NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP) <br />411 West 11th St. P.O. Box 126 Wood River NE 68883 <br />23. IMMEDIATE CAUSE (ENT ONLY ONE CAUSE PER LINE FOR la). Ibl. AND (cl) I Interval between onset and death <br />PART I <br />I (a) - e eS <br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death <br />(b) GY�M�uJL Yo \` e ("i <br />I <br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions coninbuting to the death but riot related PART <br />PART ► ^` ('� PREGNANCY <br />CAt� �'� ;...) <br />(Ages <br />III IF FEMALE. WAS THERE A <br />IN THE PAST 3 MONTHS? <br />10-54) Yes M No <br />24. AUTOPSY <br />Yes 0 No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Yes El No <br />26a. <br />26b, DATE OF I� URY (Mo, Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />F1 Accident 0 Undetermined <br />N r- <br />M <br />El Suicide F-1 Pending <br />El Homicide Investigation <br />26e. INJURY AT WORK <br />Yes No ❑ <br />261 PIA bm0ldi INJURY -S home, farm. street, factory <br />LLqq <br />office ng ( c i" <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />27a. DATE OF DEATH (Mo.. Day Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />28b. TIME OF DEATH <br />Y i <br />M <br />27b. DATE SIGNED tiMO.. Day. 'Yr.r.) <br />�- �- Q s <br />27c. TIME OF DEATH <br />/D• 5T M <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr) <br />28d. PRONOUNCED DEAD (Hour) <br />M <br />y <br />o <br />g' <br />Q J <br />N i <br />gw� <br />° ° <br />~ ° <br />27d. To the best of my, know) cu <br />causels) stated. <br />red at ate Td lace and due to the <br />I <br />l' <br />28e. On the basis of examination and/or investigation. In my opinion death occurred at <br />the time, date and place and due to the causes) stated. <br />(Signature and Title ► <br />nature and Titlel III, <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />YES 21�NO 1:1 UNKNOWN <br />I <br />El YES NO <br />YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdnq <br />L . s - a, -o �p 4m n _TS it_ N0 & <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.] <br />APR 1 0 2003 <br />EXHIBIT "A" <br />V <br />