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<br />YYFEcN TFNS COPY CARRIES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICE&
<br />SYSTEIK IT CERTFES TFEi BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOM 01Y FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST WH/CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE - -
<br />JUN122003 200307643
<br />AISANISR
<br />LINCOLN, NEBRASKA HEAD, I ANIFM N SERVICES EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAAER�¢ESFH� # D$1PPORT
<br />VITAL STATLSTIcs - 03 00225
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE UST A
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Nodine NMI Cole
<br />Female
<br />January 8, 2003
<br />4. CITY AND STATE OF BIRTH tffnol an U.S.A. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />(�1
<br />MOS. I DAYS
<br />Sc. HOURS MINIS.
<br />Grand Island, Nebraska
<br />(Yrs.) 89 Sb.
<br />April 21, 1913
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH -
<br />s 505-22-8672
<br />HOSPTAL: -- Inpatient OTHER: Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Unotmsel~, give street and number/
<br />e Park Place Health Care Center
<br />1:1 DOA ❑ Other(Specdvt
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />lid INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I Yes ❑X No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />n�Z
<br />Nebraska
<br />I Hall
<br />Grand Island
<br />536 East 12th 68801 yes © No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc)
<br />C
<br />N
<br />D
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />Clement Cole
<br />ARI
<br />14a USUAL OCCUPATION /Give kind of wVrk done dming moss 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />CL
<br />W workinp Ills, even d retired)
<br />Iomemaker
<br />-
<br />Domestic
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George A. Fuss T
<br />Julia Blaise
<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 />o
<br />t9b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />ft�7
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE - 21c.
<br />CEMETERY OR CREMATORY NAME
<br />122
<br />© Burial ❑ Remo.al
<br />Jan. 11, 2003
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremallon 1:1 Donation
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) ,
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMM �EWSE IENTER ONLY ONE CAUSE PER LINE FOR lab (b), AND (cp I Interval between onset and death
<br />PART �
<br />l
<br />lal � I
<br />e DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />I
<br />(b)
<br />DUE TO, OFP98 A CO EOUE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not related PART
<br />III IF FEMALE WAS THERE A 124
<br />AUTOPSY
<br />1 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />rn
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes R No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.) 71
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident 7 Undetermined
<br />M
<br />.
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />2�. office E OF INJURY �At homg, farm, sheet. factory
<br />SI�OY1
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />etc.
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (MO.. Day. Yr.)
<br />�
<br />�<
<br />January 8,2003
<br />�w
<br />M
<br />27b. DATE SIGNED (Ma. Day. YO
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Four)
<br />-
<br />a c
<br />Cr1
<br />g°
<br />N
<br />4:10 am M
<br />W
<br />M
<br />27d. To thili of my knowledge. death ocjWed attlie time, date antl place and due to the
<br />28e. Og, the basis•of examination And'or investigation, in my opinion death occurred at
<br />�2
<br />causes ed. J
<br />v °
<br />u'
<br />O
<br />n
<br />(Signature and Title
<br />29, DID TOBACCO USE CONTRIBU DEATH? 30.a
<br />HA ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES O ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES !0
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />D4. Ryan Crouch, 800 N. Alpha Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />10
<br />JAN 15
<br />,p
<br />YYFEcN TFNS COPY CARRIES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICE&
<br />SYSTEIK IT CERTFES TFEi BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOM 01Y FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST WH/CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE - -
<br />JUN122003 200307643
<br />AISANISR
<br />LINCOLN, NEBRASKA HEAD, I ANIFM N SERVICES EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAAER�¢ESFH� # D$1PPORT
<br />VITAL STATLSTIcs - 03 00225
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE UST A
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Nodine NMI Cole
<br />Female
<br />January 8, 2003
<br />4. CITY AND STATE OF BIRTH tffnol an U.S.A. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Maniff Day. Year)
<br />MOS. I DAYS
<br />Sc. HOURS MINIS.
<br />Grand Island, Nebraska
<br />(Yrs.) 89 Sb.
<br />April 21, 1913
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH -
<br />s 505-22-8672
<br />HOSPTAL: -- Inpatient OTHER: Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Unotmsel~, give street and number/
<br />e Park Place Health Care Center
<br />1:1 DOA ❑ Other(Specdvt
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />lid INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I Yes ❑X No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />go. STREET AND NUMBER -pnclud,4tg Z/p Code) 9e INSIDE CITY LIMITS
<br />Nebraska
<br />I Hall
<br />Grand Island
<br />536 East 12th 68801 yes © No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc)
<br />12. Q MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE tit w+fe. give maiden name)
<br />at.) (specify)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />Clement Cole
<br />ARI
<br />14a USUAL OCCUPATION /Give kind of wVrk done dming moss 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elem tary or Secondary 10 -12) College 11 -4 or 5.1
<br />W workinp Ills, even d retired)
<br />Iomemaker
<br />-
<br />Domestic
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George A. Fuss T
<br />Julia Blaise
<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 />-
<br />Clement Cole
<br />t9b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />536 East 12th, Grand Island, NE. 68801
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE - 21c.
<br />CEMETERY OR CREMATORY NAME
<br />122
<br />© Burial ❑ Remo.al
<br />Jan. 11, 2003
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremallon 1:1 Donation
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) ,
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMM �EWSE IENTER ONLY ONE CAUSE PER LINE FOR lab (b), AND (cp I Interval between onset and death
<br />PART �
<br />l
<br />lal � I
<br />e DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />I
<br />(b)
<br />DUE TO, OFP98 A CO EOUE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not related PART
<br />III IF FEMALE WAS THERE A 124
<br />AUTOPSY
<br />1 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes R No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.) 71
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident 7 Undetermined
<br />M
<br />.
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />2�. office E OF INJURY �At homg, farm, sheet. factory
<br />SI�OY1
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />etc.
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (MO.. Day. Yr.)
<br />28b TIME OF DEATH
<br />�<
<br />January 8,2003
<br />�w
<br />M
<br />27b. DATE SIGNED (Ma. Day. YO
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Four)
<br />a c
<br />J
<br />g°
<br />Januar
<br />4:10 am M
<br />M
<br />27d. To thili of my knowledge. death ocjWed attlie time, date antl place and due to the
<br />28e. Og, the basis•of examination And'or investigation, in my opinion death occurred at
<br />�2
<br />causes ed. J
<br />v °
<br />the time, date and place and due to the causes) stated.
<br />(S_ ure and T'
<br />(Signature and Title
<br />29, DID TOBACCO USE CONTRIBU DEATH? 30.a
<br />HA ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES O ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES !0
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />D4. Ryan Crouch, 800 N. Alpha Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />JAN 15
<br />l
<br />
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