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WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AAD_ S
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON-FXE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, '. WO"S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - _
<br />DATE OF ISSUANCE _ _ -
<br />AEYS:a
<br />MAY 17 2002 1f�
<br />2 0 0 3 0 9 5 6 4 ASS/S lU 1tStAtt RFC_
<br />LINCOLN, NEBRASKA HEALTH AND MUSiA7V SERNCES SYSTEM:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEIMCES F1XAaCJVAM SUMORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH - 0 2 05669
<br />-NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month Day. Year)
<br />7v
<br />C1 11
<br />May 9, 2002
<br />Iv
<br />CZ-3
<br />C'> u;
<br />o --a
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />Grand Island, Nebraska
<br />C
<br />= j
<br />C_
<br />M
<br />N a
<br />507 -32 -8341
<br />HOSPITAL Inpatient OTHER a Nursing Home
<br />Z
<br />8b. FACILITY - Name ( #not institution. give street and number)
<br />M
<br />DOA Other /Soec,ty,
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />n
<br />Yes ® No ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />C>
<br />9c. CITY. TOWN OR LOCATION
<br />(Including Zp Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />n
<br />Cn
<br />71STREETTNDNUMBEFI
<br />08 N. Custer 68803
<br />Yes ® No ❑
<br />t
<br />11. ANCESTRY fe.g.. Italian. Mexican. German, elcl
<br />12. ® MARRIED ❑ WIDOWED
<br />�J,
<br />etc.) fSoeciy�
<br />W11ite
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />MARRIED
<br />Roccene Wasserman
<br />14a. USUAL OCCUPATION (Give kindof work done during most 14b.
<br />C:y
<br />rn
<br />"a
<br />M
<br />;;a
<br />Baasch Welding Company
<br />'mv
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Henry Baasch
<br />Ruth Norbeck
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />:a3
<br />r-
<br />s�
<br />Yes: K rean War: 4 -28 -52 4 -25 -56
<br />Roccene Baasch
<br />191h . INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP(
<br />108 N. Custer, Grand Island, NE. 68803
<br />20. EMBALMER - SIG TUBE & LICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />W
<br />CEMETERY OR CREMATORY - NAME
<br />LP C
<br />Cn
<br />May 11, 2002
<br />Grand Island Cemetery
<br />Burial Removal
<br />00
<br />(n
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />RGAL:
<br />The Easterly Twenty
<br />(20) Feet of Lot One (1),
<br />Block
<br />One
<br />(1),
<br />PART
<br />Dawn Addition
<br />to
<br />the
<br />City of Grand
<br />Island, Hall County,
<br />Nebraska
<br />WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AAD_ S
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON-FXE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, '. WO"S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - _
<br />DATE OF ISSUANCE _ _ -
<br />AEYS:a
<br />MAY 17 2002 1f�
<br />2 0 0 3 0 9 5 6 4 ASS/S lU 1tStAtt RFC_
<br />LINCOLN, NEBRASKA HEALTH AND MUSiA7V SERNCES SYSTEM:
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEIMCES F1XAaCJVAM SUMORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH - 0 2 05669
<br />-NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Month Day. Year)
<br />7EDENT
<br />John Henry Baasch
<br />Male
<br />May 9, 2002
<br />4. CITY ANO STATE OF BIRTH /N not In US.A.. name counhyl
<br />5a AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />Grand Island, Nebraska
<br />(Yrs.l 50.
<br />69
<br />August 3 1932
<br />MOS. I DAYS
<br />5c. HOURS' MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba PLACE OF DEATH
<br />507 -32 -8341
<br />HOSPITAL Inpatient OTHER a Nursing Home
<br />ER Outpatient El Residence
<br />8b. FACILITY - Name ( #not institution. give street and number)
<br />St. Francis Skilled Care Center
<br />DOA Other /Soec,ty,
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />(Including Zp Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />71STREETTNDNUMBEFI
<br />08 N. Custer 68803
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black, American Indian.
<br />11. ANCESTRY fe.g.. Italian. Mexican. German, elcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (ll w#e give maiden name!
<br />etc.) fSoeciy�
<br />W11ite
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />MARRIED
<br />Roccene Wasserman
<br />14a. USUAL OCCUPATION (Give kindof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION ISpec,y only highest grade completed)
<br />of wwkmg tile, ev nil reared!
<br />Owner%perator
<br />Baasch Welding Company
<br />E or Secondary (0 -121 Colley T -4 or 5 • l
<br />��
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Henry Baasch
<br />Ruth Norbeck
<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 />Yes: K rean War: 4 -28 -52 4 -25 -56
<br />Roccene Baasch
<br />191h . INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP(
<br />108 N. Custer, Grand Island, NE. 68803
<br />20. EMBALMER - SIG TUBE & LICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />21b DATE 21c.
<br />CEMETERY OR CREMATORY - NAME
<br />fL
<br />AIZZ%
<br />May 11, 2002
<br />Grand Island Cemetery
<br />Burial Removal
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑Donalion
<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 />. I CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal- (b6 AND (c)) Interval between onset and death
<br />PART
<br />M11
<br />-`DLO
<br />L'
<br />la ` !
<br />� I InnL -al between onset and de
<br />DUE TO, OR,�AS�A'('C'OQNS�E"
<br />1,23
<br />.BENNGEE�O�F: /�
<br />(b) \ f \ l.1 a L-, I"C� c_ �5TA�_ �• \v��:� `-1 Ll
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and dean,
<br />(c) I
<br />OTHE SIGNIFICANT CO ITIONS - Conditions contributing 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 />If . r /V• is, 6 ` (Ages
<br />10 -541 Yes No
<br />Yes [M71 No
<br />Yes No
<br />26a.
<br />26b DATE OF INJURY /Mo- Day. Yr/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />EAccident ❑ Undetermined
<br />M
<br />Sm ,de ❑ Pending
<br />26e. INJURY AT WORK
<br />LL farm, street. factory
<br />261. oX1ce E OF IN JURY -SA�
<br />269. LOCATION STREET OR R F D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes No
<br />me.
<br />27a. DATE OF DEATH (Mo. Day. Yr.)
<br />28a DATE SIGNED (Mo.. Day Yr)
<br />28b TIME OF DEATH
<br />May 9, 2002
<br />M
<br />vi
<br />i
<br />27b. DATE SIGNED (Mo.. Day Yr) 27c TIME OF DEATH
<br />28d PRONOUNCED PRONOUNCED DEAD /Mo.. Day. Yr./
<br />28d. PRONOUNCED DEAD /Noun
<br />gdo
<br />May 14,2 2 5pm M
<br />in
<br />g= =�
<br />M
<br />27d. To the best my knowled .deaf cur at me. date )id Dlac nd due Io the
<br />28e. On the basis of examination add or investigation, in my opinion death occurred at
<br />° Q
<br />° ° °
<br />°
<br />causefs) stated.
<br />I
<br />the time. date and place and due to the cause(sl stated
<br />(Signature and Title) ►
<br />(Signature and Title ) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE
<br />H? 30.a
<br />HA ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />YES NO
<br />UNKNOWN
<br />YES ��
<br />D YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type o/ Print!
<br />Ryan Crouch D.O. 800 Alpha Ave., Grand Island NE. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mid. Day. Yr)
<br />z&& /
<br />MAY 1 6 2002
<br />ir- - U - -
<br />
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