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<br />WHEN TMS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OItMNA0WCQRU:Q1 FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC'MK _WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS =
<br />DA �TE OF
<br />200307665
<br />S
<br />MAR �+ 4 2003 - _ = &.-COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTHAMOWLWAN 30TVICESSYSTEM
<br />STATE Of NEBRASKA- DEPARIMEWI OF HEALTH AND HUMAN aiv,bFS � AND_ SUPPORT
<br />SAL STATISTICS - = 0 3 02906
<br />CFRTMrATF 01F T)PATI-T =
<br />I DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />C
<br />3. DATE (1FeDD rues yD 27' 2003
<br />Clemence
<br />i
<br />nn
<br />D
<br />l4ar.tniT >,�-
<br />4. CITY AND STATE OF BIRTH (a not it U SA. name eararfry)
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />m
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Abner. Da), veer)
<br />Ste MOS. DAYS
<br />51- HOURS: - MINIS.
<br />PART
<br />I(a) Gunshot wound immediate
<br />.-
<br />(b)
<br />Ashton, Nebraska
<br />(c) I
<br />I
<br />76
<br />IF FEMALE WAS THF3iE A
<br />24 AUTOPSY
<br />May 13 1926
<br />7. SOCIAL SECURTIY NUMBER
<br />M
<br />CA
<br />712 -12 -9273
<br />(Ages
<br />HOSPITAL: ❑ Inpatient OTHER: 1:1 Nursing Home
<br />ER Ou0sbent FA Residence
<br />8b. FACILITY - Nara (Mnot- WoOdr. 9W saaef andnumbed
<br />M
<br />26a_
<br />�
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />W. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />LL
<br />elf -inflicted gunshot to the head
<br />Yaz ❑ Lw ❑
<br />CL.
<br />9a RESIDENCE -STATE
<br />Z
<br />® Saudi [] Pending
<br />Bc. CITY. TOWN OR LOCATION
<br />Bd STREET AND NUMBER taMhnarg Zip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />tT;
<br />_ 1`
<br />F--+
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<br />C:)
<br />Yas ❑X No ❑
<br />10. RACE - lap, While, Blade. American Indian.
<br />11. ANCESTRY le.¢.
<br />kel ent- Marican. German. ale)
<br />12 ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (M aWa. qw maiden name)
<br />OW) ISfre v
<br />e
<br />co
<br />27b. DATE SIGNED /Ate.. Day. W../
<br />27c. TIME OF DEATH
<br />White
<br />28d. PRONOUNCED DEAD (Hourl
<br />iy
<br />NEVER DIVORCED
<br />Donna Sydow
<br />14a USUAL OCCUPATION /Diva AiMot noon/ dares oY,Yinp motif
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<br />14b. KIND OF BUSINESS INDUSTRY
<br />115. EDUCATION (Seedy only N west grade cwnPleled)
<br />d rp -g Mk
<br />8
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<br />" la,zt college l0 or 5-1
<br />Tire Salesman
<br />cause(SI staled.
<br />2
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Frank Fredrick
<br />Frances Michalek
<br />18. WAS DECEASED
<br />EVER IN US ARMED FORCES?
<br />NTED?
<br />18a INFORMANT - NAME -
<br />(Yesk no. a Lek)
<br />(8 yes, g- war and does of sambas(
<br />31. NAME AND ADDRESS OF CERTIFIER fPHYSKAAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Prxgl
<br />c-r
<br />32a. REGISTRAR
<br />326. DATE FILED BY REGISTRAR (Ate., Day Yr.)
<br />Donna Fredrick
<br />MAR 14 2003
<br />�\
<br />:pIz
<br />CD CD
<br />GJ
<br />Cp
<br />C17
<br />�
<br />WHEN TMS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OItMNA0WCQRU:Q1 FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC'MK _WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS =
<br />DA �TE OF
<br />200307665
<br />S
<br />MAR �+ 4 2003 - _ = &.-COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTHAMOWLWAN 30TVICESSYSTEM
<br />STATE Of NEBRASKA- DEPARIMEWI OF HEALTH AND HUMAN aiv,bFS � AND_ SUPPORT
<br />SAL STATISTICS - = 0 3 02906
<br />CFRTMrATF 01F T)PATI-T =
<br />I DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2. SEX
<br />3. DATE (1FeDD rues yD 27' 2003
<br />Clemence
<br />M. Fredrick
<br />Male
<br />l4ar.tniT >,�-
<br />4. CITY AND STATE OF BIRTH (a not it U SA. name eararfry)
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Sa. AGE -.LaM Biraway
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Abner. Da), veer)
<br />Ste MOS. DAYS
<br />51- HOURS: - MINIS.
<br />PART
<br />I(a) Gunshot wound immediate
<br />fYrs.l
<br />(b)
<br />Ashton, Nebraska
<br />(c) I
<br />I
<br />76
<br />IF FEMALE WAS THF3iE A
<br />24 AUTOPSY
<br />May 13 1926
<br />7. SOCIAL SECURTIY NUMBER
<br />-
<br />Ba PLACE OF DEATH
<br />712 -12 -9273
<br />(Ages
<br />HOSPITAL: ❑ Inpatient OTHER: 1:1 Nursing Home
<br />ER Ou0sbent FA Residence
<br />8b. FACILITY - Nara (Mnot- WoOdr. 9W saaef andnumbed
<br />2708 W . Anna
<br />26a_
<br />❑ DOA ❑ Other (aveedrr
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />W. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />elf -inflicted gunshot to the head
<br />Yaz ❑ Lw ❑
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />® Saudi [] Pending
<br />Bc. CITY. TOWN OR LOCATION
<br />Bd STREET AND NUMBER taMhnarg Zip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />126f.
<br />home garage
<br />Grand .Island
<br />12709 W. Anna 68803
<br />Yas ❑X No ❑
<br />10. RACE - lap, While, Blade. American Indian.
<br />11. ANCESTRY le.¢.
<br />kel ent- Marican. German. ale)
<br />12 ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (M aWa. qw maiden name)
<br />OW) ISfre v
<br />ISPecilyl
<br />12:00 am
<br />M
<br />27b. DATE SIGNED /Ate.. Day. W../
<br />27c. TIME OF DEATH
<br />White
<br />28d. PRONOUNCED DEAD (Hourl
<br />iy
<br />NEVER DIVORCED
<br />Donna Sydow
<br />14a USUAL OCCUPATION /Diva AiMot noon/ dares oY,Yinp motif
<br />M
<br />14b. KIND OF BUSINESS INDUSTRY
<br />115. EDUCATION (Seedy only N west grade cwnPleled)
<br />d rp -g Mk
<br />8
<br />g
<br />,° v
<br />" la,zt college l0 or 5-1
<br />Tire Salesman
<br />cause(SI staled.
<br />2
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Frank Fredrick
<br />Frances Michalek
<br />18. WAS DECEASED
<br />EVER IN US ARMED FORCES?
<br />NTED?
<br />18a INFORMANT - NAME -
<br />(Yesk no. a Lek)
<br />(8 yes, g- war and does of sambas(
<br />31. NAME AND ADDRESS OF CERTIFIER fPHYSKAAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Prxgl
<br />I
<br />32a. REGISTRAR
<br />326. DATE FILED BY REGISTRAR (Ate., Day Yr.)
<br />Donna Fredrick
<br />2708 W_ Anna Grand Tcl and - mr. h'AR(1 A
<br />20. EMBALMER - SIGNATURE d LICENSE NO.
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21 C. CEMETERY OR CREMATORY - NAME
<br />y%✓) 1092
<br />❑X 9udal ❑Removal
<br />Mar 4, 2003
<br />Grand Island City
<br />228. FUNERAL - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Curran Funeral Chapel
<br />❑`''""'"°e ❑Dtl1800n
<br />3168 W. Stol . lev Park Rd. Grand Island NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR NO.. CRY OR TOWN. STATE. LP)
<br />3005 South Locust Street Grand Island NE 68801
<br />23 IMMEDIATE CAUSE- (ENTER ONLY ONE CAUSE PER LINE FOR Ian. ft AND (c)) Interval between onset and death
<br />PART
<br />I(a) Gunshot wound immediate
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF, I aaerval balvraert Onset e!N dear
<br />(c) I
<br />I
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditws conalbrAng b the death txrt not retailed PARTJI
<br />IF FEMALE WAS THF3iE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />a
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10-541 Yes No
<br />Yes No X
<br />Yes No
<br />26a_
<br />?Bb. DATE OF INJURY (Ate_ Day. YrJ
<br />2BC. R R}IU
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />❑ A�OeM L] t,m
<br />2/28/03
<br />12m�1�m
<br />t.A
<br />elf -inflicted gunshot to the head
<br />® Saudi [] Pending
<br />26e. INJURY AT WORK
<br />PLACE OFD U Y - hor7ra, farm. street, factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ H..d. Mveat;gabw
<br />Yes El No®
<br />126f.
<br />home garage
<br />2708 W Anna St, Grand Island NE
<br />27a DATE OF DEATH tAb_ Day. Y / -
<br />28a. DATE SIGNED (Ate_ Day. Yrl
<br />26b. TIME OF DEATH midnight
<br />a<
<br />as �
<br />-
<br />12:00 am
<br />M
<br />27b. DATE SIGNED /Ate.. Day. W../
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tAb.. D y, Yr./
<br />28d. PRONOUNCED DEAD (Hourl
<br />iy
<br />P
<br />�go
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<br />T
<br />igLg
<br />March 1, 2003
<br />12:45 am
<br />M
<br />8
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<br />,° v
<br />27d To the best of my knowledge. death oceared A the Sme, date and place and due to the
<br />25e. On the beats of examination ant /or twesDgaaon, in my op bon dewl� occurred at
<br />cause(SI staled.
<br />U a
<br />the tine, date and Ca s ateid. !/
<br />and T'Ite ►
<br />and TMe le
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />NTED?
<br />El YES ® NO ❑ UNKNOWN
<br />❑ YES NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER fPHYSKAAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Prxgl
<br />Sgt E Edwards, GIPD, 1 1 S Locust, Grand Island, NE 68801
<br />32a. REGISTRAR
<br />326. DATE FILED BY REGISTRAR (Ate., Day Yr.)
<br />MAR 14 2003
<br />v -
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