200309117 - Laserfiche WebLink

Browse

10030141� 4*1EN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAT 1 ►dND HUMAN fERVICES SYSTE14 RCERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINNAUrd ME WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL s t iIflCH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE JUG JUL 14 2003 'QF�R ,- %BAR LINCOLN, NEBRASKA HEALTHAND EM/ STiUSOF ASA- DWAIii31fMCWTiWAU N AND IIUMMS8R11'ICBSPOi11� EBAII�i T ATISM ccER�cATE OF DEATH 02 12738 1. OECEDO'N'T °NAME FIRST WADDLE LAST 2 SEX 3, DATE OF DEATH Abw2 Dar ray Colene Mildred Opp Female October 22, 2002 A Cm Mq STATE OF 9WTN 10 0*1 USA. A.ANtemAwyl 5s AGE • LM IIND®f YEAR LINDEN 1 DAY 9 DATE OF 9IITN AterDe Owr vay — Wilton, MN "'s' 82 54 Mas DAYS 5c.NO'm "N" July 2, 1920 T SOCIA.. SECMw NUWIFR as PLACE of DEATH 507 -12- 7520 "- fSP1iu ® '^8 E-- ❑ ++ ❑ ER QUOMm ❑ PA&ftt. _ M FACRrtY -N.nw f7rorstlAMOL?WaMCaMNnDS/ _ St. Francis Medical Center ❑DOA [❑ OtwR law.&, & CITV TONNORLOCATNONOFMTH D6. WSIDECfT UNIRs AL COUNTY OF DEATH Grand" Island Y.A [3, ❑ Hall _ 98 RESIOrATE - STATE 9b COUWN I °.t CFM TORN 09 LOCATION 19d. STREET AND p{ANER *&.*Vlo Ceem 19f 06" CRY UYrtS Nebraska ; Hall Wood River 1401 East St. 68883 YwKI NtD❑ 10. PACE -pq, RAwt. Black AorRCrllnati0r. 11. ANC STRYwq .ae.A Almes". Gwn1 exi 12 ❑ MARRIED ® WIOOWED t3 NAME Oi SPOUSE 1'.41/,1 eC,Idr "At.e/I d`I'S`°i ite `shish /German NEVER DIVORCED 14 USUAIOOCUPATION RG.w krlldwW dbx,at.Vq e.py tap KIND OF 9USINESS INDUSTRY EDUCATION :SWUygrly 101RIPIAAkA dwo"wlptll..twn sKNAVA romm", Sttawr y 10,21 C;DUpt '•�ns•� Homemaker Domestic — 19 FATHER-NW MIS? NICOLE I-AST 17 MOTHER FIRST MIDDLE WIDEN SUT.sA,E William Andersen Minnie Keechler 19 WAS DECEASED EYER IN US. ~0 FGROiS> 190 WFORMAW -NAM hgt ®.Dully sA yes. pvr wr tn6 CrudAwvKwil � Ju Cale 14 MFpRAtANT MA4fA ADD —n STREET OP. RF 0 N0. CITY OR TOWN Sy ELP) 7469 Towchester Ct., Alexandria, VA 22315 20 ENBALIAN- SIONA7URE9CICENEE NO 216 NETHODOFD6POSITgN 21D DATE 2RC CEMETERYORCREWT04Y NAME 7VK� df xs..dt� 'It2 IA,181 ❑P&Iw.aII- 26, 2002; Wood River Cemetery -Oct. 2ft FUNERAL HOME -NAME 211 CEMETERY OR CREWTOWr LOCATION CITY OR TOWN STATE Apfel Funeral Home C.O. ❑D'. 1 Wood River, Nebraska 2M FL'*W NW6E ADOIESS WUEET OR RIM 110 CRY OR TOWN. STATE. DP) i 411 West 11th St., P.O. Box 1260 Wood River, NE. 68883 Y.R NLAEOIAlE CAUSE PART LINE &I IENTER ONLY ONE CAUSE PER NE FOR w AND Ic# Y.ttivai Dt/A.e" dltn a,7� aeay. 7 day, -A CUE TO. dk AS ff'•NS_ 1E --- larvae D0I0.an orrw m ac.r { DUE 10 ORASACONSEOUENCEIx -- trr.a oN..enDew oca► 1 I�, OTHER SNGNIFICAN7 CONOITIONS - Ca.I01w Cpl X&V w 171! ARilD Out "d;awRae �PART , •mot / . • .r - J A �� Cj9A PREGNANCY IN THE PAST 3 MONTNS> EkAAIINER OR CORONEP- (�(/ _ /i� CV4 IAgn 10 -541 Yes ND Yas� No f Yas Iq El 256 DATE OF OLARRV 1w. Dar yxj 2& HOUR OF ILAJRY 1 261 DESCRIBE NOW INJURY OCCURRED )1t ❑ A=4ws [3 U"dearm"w1 ; M $,s1:dt Ej FWIDI�g 1261 ILIURY AT2N PLACE OLIN RY'A1Irony.farm sssel 4MV 269 LOCATION STET OR RFD NO �i1r OR TOWN STATE Nwaft in�.A I —11-13, dFC DPMt^Q ODteN 278 DATE OF DEATH IMO Dar Vil 2ND LIME GF DEATH 1 26a DATE SIGNED r6b Dar v.. jli IS - LL -z-L, a s M '27b DATE. SNGNEG !AU Dur vr/ 27C TIME OF DEATH —� 2ft PRONOUNCED CLAD !MU Aw. v:; j290 pROhGuNCED DEAD �Nn,,. 1271 T""w wAct k E ; { 4 R"Y "m✓ee9e awl acvroD A tle,.1M. awe am dace an0 Due 7o aw • 2.e O" Ow Ot.s d Nk"1.IAIw1 and a n cp'.t" aOalr. I�auna0 y eweaYS! swwtl. Iw ant. dM aW 0K* a"1 Doe w W4 C , S#ilsl NOW ' aae/TMIa vN..p /va Y " i II2d Od1708ACC0 USE LONT,.BUrE TO THE DEATM> 30a NASORGANOR TISSUE DONATION BEEN CONSIDERED' 30D WAS CONSENT GRANTED' 7" It/ t !YI YES ❑ N(Y ❑ UNKNOWN 1 ❑ YES %1- n .ES r NC 31 NAME AND ADDRESS OF CERTIFIEP !"SICII.N. CCgONER S PHYSIOOW OR COUNTY ATT -a'EYi 7—W, Anne Morse M.D. 729 N. Custer, Grand Island, NE. 68803 Lf t I e —a