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WHEN THYS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 8ERWZS
<br />SYSTEMI IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R9P9 XE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIWWG I IS.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS *_7t
<br />DATE OF ISSUANCE --
<br />5/29/2003 E�rS;C _ T
<br />ASSYSl4Nf- sfATERE 'A �
<br />LINCOLN, NEBRASKA HEALTH ANDMiMN SERVICE# , -
<br />s
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYIOSSRi 010E AN-D SFMiPORT
<br />03 05890
<br />VITAL STATISTICS -
<br />d- 1171DTTFTI -ATP (1F n1PA7TY.
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />IMav23
<br />Charles Wilb77Z Alb ht
<br />Male
<br />2003
<br />4. CITY AND STATE OF BIRTH tdna k U.S.A. name country)
<br />5 -Last
<br />NDER 1 YEAR
<br />UNDER 1 DAY 6. DATE OF BIRTH tMOndr. Day. Year)
<br />OS.I DAYS
<br />Portland, Oregon
<br />26a
<br />5c. HOURS' MINIS. January 4, 1924
<br />7. SOCIAL SECURTIY NUMBER
<br />DEATH
<br />❑ Inpatient O_THER: ❑ Nursing Home
<br />538-12-0719
<br />_.-
<br />❑ ER Outpabent ❑ Residence
<br />® C
<br />8b. FACILITY - Name prior msNlWion. give street and number/
<br />St. Francis Skilled Care
<br />❑ DOA Other tspec, ",�>»� -
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8tl. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yea � No ❑
<br />Hall
<br />Be. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />C1
<br />n
<br />z
<br />Hall
<br />Grand Island
<br />1044 S. Vine 68801
<br />Ye, X❑ No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g_ Italian. Mexican. German, etc)
<br />D
<br />Q
<br />ela I (Specify)
<br />(Specify) American
<br />CJ
<br />U%
<br />O
<br />31. NAME AND ADDR OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />MARRIED
<br />321L REGISTRAR
<br />14a USUAL OCCUPATION /Give kindd work done draing most
<br />141). KIND OF BUSINESS INDUSTRY
<br />w p _i
<br />(Specify only highest grade completed)
<br />N
<br />of working life. even drekredl � �
<br />Draftsman
<br />Construction
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Valentine Albri ht
<br />C D
<br />N
<br />19a INFORMANT -NAME
<br />(Yes. no. or unk) 16-0-4943/10-22-1952 gi
<br />Joann Albright
<br />Yes
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />M
<br />r, z
<br />0
<br />CL
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />11 Burial ❑Removal
<br />121C.
<br />May 24,2003
<br />Westlawn Crematory
<br />22a FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />©aema- ❑-af-
<br />Grand Island, Nebraska
<br />FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP(
<br />929 S. Locust St., Grand Island, Nebraska 68801
<br />r .-.___ _... .. ,.....,_ ..�.. , ..� �..., ,__�� I Interval between onset and Beam
<br />W Tt M-
<br />CJ
<br />CD
<br />w cn
<br />c°
<br />z
<br />Cn
<br />o
<br />See O,#tacbea lego-1
<br />900307478
<br />WHEN THYS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 8ERWZS
<br />SYSTEMI IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R9P9 XE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIWWG I IS.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS *_7t
<br />DATE OF ISSUANCE --
<br />5/29/2003 E�rS;C _ T
<br />ASSYSl4Nf- sfATERE 'A �
<br />LINCOLN, NEBRASKA HEALTH ANDMiMN SERVICE# , -
<br />s
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYIOSSRi 010E AN-D SFMiPORT
<br />03 05890
<br />VITAL STATISTICS -
<br />d- 1171DTTFTI -ATP (1F n1PA7TY.
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />IMav23
<br />Charles Wilb77Z Alb ht
<br />Male
<br />2003
<br />4. CITY AND STATE OF BIRTH tdna k U.S.A. name country)
<br />5 -Last
<br />NDER 1 YEAR
<br />UNDER 1 DAY 6. DATE OF BIRTH tMOndr. Day. Year)
<br />OS.I DAYS
<br />Portland, Oregon
<br />26a
<br />5c. HOURS' MINIS. January 4, 1924
<br />7. SOCIAL SECURTIY NUMBER
<br />DEATH
<br />❑ Inpatient O_THER: ❑ Nursing Home
<br />538-12-0719
<br />_.-
<br />❑ ER Outpabent ❑ Residence
<br />® C
<br />8b. FACILITY - Name prior msNlWion. give street and number/
<br />St. Francis Skilled Care
<br />❑ DOA Other tspec, ",�>»� -
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8tl. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yea � No ❑
<br />Hall
<br />Be. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlncludmg Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1044 S. Vine 68801
<br />Ye, X❑ No
<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 /lt wife. give maiden name)
<br />ela I (Specify)
<br />(Specify) American
<br />NEVER DIVORCED
<br />Joann Stuckenschmidt
<br />White
<br />31. NAME AND ADDR OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />MARRIED
<br />321L REGISTRAR
<br />14a USUAL OCCUPATION /Give kindd work done draing most
<br />141). KIND OF BUSINESS INDUSTRY
<br />I IS. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -12) College 11 -4 or 5 -1
<br />12
<br />of working life. even drekredl � �
<br />Draftsman
<br />Construction
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Valentine Albri ht
<br />Eleanor Hardman
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? Korean War
<br />19a INFORMANT -NAME
<br />(Yes. no. or unk) 16-0-4943/10-22-1952 gi
<br />Joann Albright
<br />Yes
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1044 S. Vine, Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE. NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />11 Burial ❑Removal
<br />121C.
<br />May 24,2003
<br />Westlawn Crematory
<br />22a FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />©aema- ❑-af-
<br />Grand Island, Nebraska
<br />FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP(
<br />929 S. Locust St., Grand Island, Nebraska 68801
<br />r .-.___ _... .. ,.....,_ ..�.. , ..� �..., ,__�� I Interval between onset and Beam
<br />PMT I
<br />- ? -lal - t Interval between onset and death
<br />DUE TO, OR AS A CONSEOU OF:
<br />(b)
<br />DUE T0. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contriblAng to the death but not related
<br />PART III IF FEMALE. WAS THERE A
<br />I
<br />2a AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONERn
<br />PART
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />If UJi7
<br />(V/
<br />(Ages 10 -541 Yes No D
<br />Yes D No
<br />Yes No
<br />26a
<br />26b. DATE OF INJURY (Ma. Day. Yr./
<br />26c. HOUR OF INJURY
<br />2Bd. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined
<br />I
<br />M
<br />Suicide R Pending
<br />26s. INJURY AT WORK
<br />261. P
<br />buQldit INJURY - Athhomp, farm. street. factory
<br />ayl
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No 1:1
<br />e
<br />27a. DATE OF DEATH (Mo.. Day. Yr./
<br />28a. DATE SIGNED (Mo.. Day. Yr) 28b. TIME OF DEATH
<br />May 23, 2003
<br />M
<br />27b. DATE SIGNED /Ma. Day. Yrl 27c. TIME OF DEATH
<br />is
<br />vii g 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Flour)
<br />1.00. P.M
<br />8
<br />° 27d. To ft best of my knowled e. death occurred at the time, date and place and due to the
<br />° 28e. On the tlaele M examination and• to the ca JMion, in my opinion death occurred at
<br />~ ° a the time, date and place and due to the cause(s) stated.
<br />cause(s) stated.
<br />W V
<br />IS nature and Tills 10 (Signature and Tftl
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3Qa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />15
<br />❑ NO ❑ UNKNOWN ❑
<br />YES �NO ❑ YES NO
<br />YES
<br />31. NAME AND ADDR OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />Anne K. Morse M.D. 729 N.Ciouster Ave.X Grand Island NE 68803
<br />321L REGISTRAR
<br />32b. DATE FILED BY REGISTRAR
<br />MAY /Afg Day No3
<br />
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