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Rev. 11/97 <br />Z E <br />W <br />0 1 <br />W <br />U <br />W S <br />1 <br />LL <br />01 <br />LU <br />Z U <br />co <br />M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH 200307383 <br />ENT-NAME FIRST MIDDLE LAST <br />2, SEX <br />3. DATE OF DEATH /Month. Day. Year) <br />G! Richard Leon Bell <br />Male <br />March 17, 2002 <br />4. CITY AND STATE OF BIRTH Of 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 (Month, Day. Year/ <br />Grand Island, Nebraska <br />(Yrs.) 57 <br />July 6, 1944 <br />Sb. MOS. i DAYS <br />5c. HOURS MINS. <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />505 -52 -7333 <br />HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home <br />® ER Outpatient ❑ Residence <br />81b. FACILITY -Name (/f not institution, give street and number) <br />St. Francis Medical Center <br />❑ DOA ❑ Other(Specdyi <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Grand Island, Nebraska <br />Yes ® No ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />91b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1221 N. Pine 68801 <br />Yes ® No C <br />10. RACE - (e.g., White. Black. American Indian, <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />12. © MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE ///wile. give maiden name) <br />etc.) fSpecify) <br />White <br />(Specify) <br />American <br />NEVER DIVORCED <br />MARRI D <br />Nyla C. Potratz <br />14a. USUAL OCCUPATION /Give kind of work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ISpeciy only highest grade completed) <br />o/ working life, even ifre9rare <br />Fork Lift Mechanic <br />Clark Lift Co. <br />Elementary - Qa:ondary 10 -12) College It -4 or 5 -) <br />12 <br />16. FATHER - NAME FIRST MIDDLE LAST <br />17, MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Leo Bell <br />Edna Dickman <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no. (it yes. <br />,' .1 <br />-1967 <br />Nyla C. Bell <br />28e. On the basis of a anti anon r nvesligation, my opinion death occurred at <br />19b. INFORMANT MAILING ADDRESS . ISTREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) <br />causelsl stated. <br />1 21 North Pine Grand Island, Nebraska 68801 <br />the lime, dale an pl a an u t the causelsl sled.: <br />EMALMER - SIGNATURE 8 LICENSE NO. G+�� <br />21 a. METHOD OF DISPOSITION <br />21 b. DATE 21 <br />C. CEMETERY OR CREMATORY -NAME <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />U <br />❑ Burial ❑ Removal <br />March 2002 Westlawn <br />Crematory <br />22a. FUNERAL 0ME -NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Jerom E Janulewicz, Hall County Atty, 117 E lst. Grand Island, NE 68801 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) <br />Apfel- Butler- Geddes <br />®Cremation 1:1 Donator <br />Grand Island Nebraska <br />221b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second Street Grand Island, Nebraska 68801 <br />,...c...r.. c �r.�a Irn. cn ­11r 1r1c 1.- ran lal. lot, - Icg <br />PART <br />I lal Cardio respiratory arrest <br />DUE TO, OR AS A CONSEQUENCE OF: <br />(b) Coronary artery disease <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Interval mm an onset ana attain <br />1 hour <br />I <br />Interval between onset and death <br />I Interval between onset and death <br />I <br />iv <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A <br />24. AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />(Ages 10 -54) Yes F No F <br />I Yes F No <br />Yes No <br />26a. <br />26b. DATE OF INJURY (Ma. Day. Yr./ <br />26c. HOUR OF INJURY <br />28d. DESCRIBE HOW INJURY OCCURRED <br />Accident � Undetermined <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />261. PLACE OF INJURY - (Sqt home, farm. street. factory <br />o 8ice building. etc. <br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes No <br />❑ ❑ <br />pacify) <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a, DATE SIGNED (Mo., Day. Yr) <br />28b. TIME OF DEATH <br />�< <br />A7 <br />March 18 2002 <br />7: 34 pm M <br />Y <br />i <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED /Mo.. Day, r <br />DE <br />28d. PRONOUNCED DEAD (Hour) <br />g� <br />M <br />_ <br />arch 1 200 <br />7:34 pm. <br />,' .1 <br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the <br />° °¢ $ <br />~ <br />28e. On the basis of a anti anon r nvesligation, my opinion death occurred at <br />causelsl stated. <br />a <br />the lime, dale an pl a an u t the causelsl sled.: <br />(Signature and Title ► <br />TT /'+ <br />IS nature and Title Hall o A t t <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />-Co <br />ONSENT G ANTED? <br />❑YES ❑ NO UNKNOWN <br />YES NO <br />YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY/ (Type or Print) <br />Jerom E Janulewicz, Hall County Atty, 117 E lst. Grand Island, NE 68801 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) <br />FOR VITAL STATISTICS USE ONLY <br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE <br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. <br />r� <br />F L- BUTLER- EDDES FUNERAL HOME <br />