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lT � WHEN THIS COPY CAM MS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERT)RES THE BELOW TO BE A TRUE COPY OF THE ORIGINL E WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STi414S_ 3FCI /CH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE N ., JUL 2 5 2001 200308814 LINCOLN, NEBRASKA HEALTH A1W~. STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUaW _z Am S MP.T VITAL STATISTICS - 01 0591.5 CERTIFICATE OF DEATH----- _ 1 DE'.EDENT - NAME FIRST MIDDLE LAST 2 SEX - -- - 3 DATE OF DEATH )M—th Day 1,a, M n May 26, 2001 4 CITY AND STATE OF BIRTH Itsnot m U SA.. name country) Sa AGE - Lasl Binhday � o m Wynona Minnesota !Yrs'i 80 December 09, 1920 Sb MOS DAYS Sc. HOURS MINS 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 472 -12 -4605 HOSPITAL ❑ Inpatient OTHER ® Nurgng Hdroe May 26, 2001 ❑ ER Outpatient ❑ Residence fib FACILITY Name lit not—latron. givestreet and number) C) _ � Z v 0 _ .- t. �, , C_ r- r- = --, ° �. Grand Island 1918 W Charles, 68803 j Yes © No ❑ 10 �g�lle_g_, White. Black. Amencan Inaian. y t2 � MARRIED ❑ WIDOWED 13 NAME OF SPOUSE 111 mfe gwe maiden name) ;„ _ l ngfish -� Q ° n N 14a 'USUAL OCCUPATION /Give Irmdot work doneduring most s ab KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) c: �' Own Home O "� W 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Loyde Eugene Pfeiffer Marian Gertrude Coleman _ p r , ' 3 Co yr i CD ° 1 �i � 0I (n Z O lT � WHEN THIS COPY CAM MS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERT)RES THE BELOW TO BE A TRUE COPY OF THE ORIGINL E WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STi414S_ 3FCI /CH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE N ., JUL 2 5 2001 200308814 LINCOLN, NEBRASKA HEALTH A1W~. STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUaW _z Am S MP.T VITAL STATISTICS - 01 0591.5 CERTIFICATE OF DEATH----- _ 1 DE'.EDENT - NAME FIRST MIDDLE LAST 2 SEX - -- - 3 DATE OF DEATH )M—th Day 1,a, Elizabeth Ann Steinson Female May 26, 2001 4 CITY AND STATE OF BIRTH Itsnot m U SA.. name country) Sa AGE - Lasl Binhday UNDER 1 YEAR UNDER t DAY 6 DATE OF BIRTH rMonm Dav Year) Wynona Minnesota !Yrs'i 80 December 09, 1920 Sb MOS DAYS Sc. HOURS MINS 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 472 -12 -4605 HOSPITAL ❑ Inpatient OTHER ® Nurgng Hdroe May 26, 2001 ❑ ER Outpatient ❑ Residence fib FACILITY Name lit not—latron. givestreet and number) Hamilton Manor ❑ DOA ❑ Other ISoeC,fy' 8c CITY TOWN OR LOCATION OF DEATH Aurora ed INSIDE CITY LIMITS ! 8e COUNTY OF DEATH Yes g] No ii❑ Hamilton 9a RESIDENCE - STATE 19b COUNTY 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER )Including Zp Codes —7 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1918 W Charles, 68803 j Yes © No ❑ 10 �g�lle_g_, White. Black. Amencan Inaian. 11.,,jjANCE�SYJTRY leg Italian Mexican. German, i t2 � MARRIED ❑ WIDOWED 13 NAME OF SPOUSE 111 mfe gwe maiden name) �?R�AACIE W ol[8 ") l ngfish ❑ NEVER DIVORCED John A Steinson MARRIED 14a 'USUAL OCCUPATION /Give Irmdot work doneduring most s ab KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) I omegl a%r erect) Own Home Elementary or Secondary 10 12) Coll2le n 4 or b• 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Loyde Eugene Pfeiffer Marian Gertrude Coleman 18 WAS ULUEASEU EVEH IN US AHMEU FUHCES! 19a INFUHMANI NAME Who or I IT yes give war and dales of services) John A Steinson 'v i 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN STATE. ZIP) 1918 W Charles, Grand Island, Nebraska 68803 20 EMBALMER - SIGNATURE B LICENSE NO 21a METHOD OF DISPOSITION 1 21b DATE 1 21C CEMETERY OR CREMATORY NAME NOT EMBALMED ❑ Bunal ❑ Rempval 05/26/2001 Central Nebraska Crematory 22a FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATION Higby Mortuary] cremator ❑ Dpnatipn Gibbon, Nebraska CITY OR TOWN STATE 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) P.O. Box 204 Aurora, NE, 68818 -0204 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR i, bl. AND (c)) 1 Interval between onset and nealr PART I 1 lal DUE TO, OR AS A CONS1{EOUENCE OF'�) Interval between onset and death (bl i�s x 1- (�,. "1 ) a� DUE TO OR AS A CONSEQUENCE OF Interval between onset and ream. OTHER SIGNIFICANT CONDITIONS - Conditions Contributing to the death but not related PART �t Y PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTH S2 fAge, 10 -541 yes No 2d AUTOPSY Yes No 25 WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER' Yes F7 No 26a 26b. DATE OF INJURY (MO. Day. Yr) 26c HOUR OF INJURY ! 26o DESCRIBE HOW INJURY OCCURRED Accident Untletermtned M Suicide 'j—] Pending Homicide Investigation 26e INJURY AT WORK Yes No ❑ ❑ 261. PLACE OF INJURY - At home. farm. ;trees. factory office building. etc /Specify) 26g. LOCATION STREET OR R D. NO CITY OR TOW �N STATE 27a. DATE OF DEATH IMo Day. Yr) 26a DATE SIGNED (Mo Day Yr I 28b TIME OF DEATH May 26, 2001 _ M ur'-i �8 0 g m r te` � w z � o 0 0 - 27D DATE SIGNED (MO.. Day Yr/ 5 2U L)( 27c TIME OF DEATH 4:15 A � M 28c PRONOUNCED DEAD IMO Day. Yr) - 28d. PRONOUNCED DEAD /Hour) M 271 To 1 e best of my k owl tlea urr at Me timZdf and pla�g and due to the causel5l stated ) ,�,� ] nature and Title) ► , V L/l.t- -K -i ��- 28e On the basis of examination and or investigation. in my opinion tleath occurred as the lime, date and place and due to the causef s) statedSi , (Signature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TCYTHII DEATH. 30.a HAS OR" TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' N1 YES ❑ NO 1:1 UNKNOWN [] YES NO [] Y ES NO 41 NAMI, ANU AUUHEJJ OF_tH I IFICH I Yrlr Il.IAN VHUNEH J YHYJIUTAN UH_UUN I Y A I I UHNEY I Iybe Or F'rinl' Jeff Muileiibuit, M.D. 609 O Street Aurora, NE 68818 32a 'REGISTRAR 32b DATE FILED BY REGISTRAR /MO Day Yr ) ,� MAY 3 0 200.1