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t <br />;� a <br />WHEN THYS COPYCAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND - HUMMN SERVICES <br />SYSTEM, RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGIft49A0tdft70Nf1,LE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST gjCH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />20030900 <br />APR 3 2003 = _ ; CQCWER., <br />4SMS_TA1Y T717F 8iAR <br />LINCOLN, NEBRASKA HEALTH AND M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SUPPORT <br />vTTAL STATISTICS <br />CERTIFICATE OF DEATH `" 03 03644 <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month. Day. Year/ <br />Marie W. Shanks <br />Female I <br />March 29, 2003 <br />4. CITY AND STATE OF BIRTH /Nrlot o USA.. name country) <br />5a. AGE - Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /MOnIn. Day Year/ <br />Hildreth, Nebraska <br />(Yrs.l 88 sb.IaoS <br />September 15, 1914 <br />DAYS <br />Sc. HOURS MINS <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />506 -26 -9130 <br />HOSPITAL ❑ Inpatient OTHER O Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (l/not msdtulim give street and number/ <br />Tiffany Square Care Center <br />❑ DOA ❑ other /SOecdy, <br />8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island,'. Yes ® No ❑ <br />I Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />gc. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER (lnctudirg L;" 03 <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />I Hall <br />Grand Island <br />3119 W. Faidle y Ave. <br />Yes ® No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY leg.. Italian. Mexican. German, etcl <br />12. ❑ MARRIED ® WIDOWED <br />13. NAME OF SPOUSE pl wile. give maiden name/ <br />etc.) (Specify) White <br />(Specify) American <br />NEVRER DIVORCED <br />Paul F. Shanks (Dec) <br />14a. USUAL OCCUPATION /Give kind of work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION iSpeciy only highest grade completed) <br />of working li/e, even 8mtrred) <br />Bookkeeper <br />Credit Union <br />Elementary or Secondary 10 -121 College It -4 or 5.1 <br />12th Grade <br />16. FATHER -NAME FIRST MIDDLE LAST 1 <br />FIRST MIDDLE MAIDEN SURNAME <br />Rev. Oscar Paul Hausmann <br />Magdalena Baker <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no. or unk.) pt yes. give war and dates of services) ) <br />I <br />No -- - - - - -- <br />Pauline Preisendorf <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP) <br />7815 N. Sky Park Rd., Grand Island, Nebraska 68801 <br />20. EM ER SIGNA 8 SE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY - NAME <br />1 . 41191 <br />Burial ❑Removal <br />Aril 2 2003 <br />WestlaWI1 Memorial Park <br />22a. RAL HOM A AME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston-Son ermann F.H:. <br />0 0renidon El Do-"' <br />Grand Island Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />21 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (c)) Interval between onset and death <br />PART I <br />' (a) COPD '�-40 YRS <br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death <br />(b1 TOBACCO ABUSE 60 YRS <br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death <br />II <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contribulirg to the death but not related PART <br />III IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />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 -541 Yes No � <br />Ves No <br />1, Yes <br />'1 <br />No <br />26a. <br />26b. DATE OF INJURY (Mo., <br />HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />76c <br />M <br />❑ Suicide Pending <br />26e. INJURY AT WORK <br />PLACE OF. INJURY <br />� , farm, street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />O Homicide Investigation <br />Yes No <br />❑ ❑ <br />T161. <br />ice build/ etc. -SPech <br />27a. DATE OF DEATH (MO.. Day. Yr.) <br />28a. DATE SIGNED (W... Day. Yrl <br />28b. TIME OF DEATH <br />a <br />+- MARCH 29 2003 <br />saw <br />M <br />g <br />27b. GATE SIGNED (MO. Day. Yr/ <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD IMO.. Day, Yr/ <br />M. PRONOUNCED DEAD (Fount <br />8 <br />MARCH 31,2003 <br />,r 4:00 A M <br />8 <br />M <br />AF5 <br />27d. To the best ol my knowledge. death occurred at the time, date a e and due to the <br />28e. On the basis of examination and /or investigation, in my opinion death occurred at <br />5 <br />~ ° K <br />I <br />► ` �Sueats) stated. <br />X <br />, the time. data and pace and due to the cause(sl stated. <br />(Signature and Tide <br />re and Title <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEAT)UNOWN 30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />YES ❑ NO ❑ ❑ YES 9-9. <br />❑ VES NO <br />X <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Or Pri <br />32a FTEOST R <br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr) <br />APR 2 2003 <br />