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WHENTHIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL eCOlf?D�OAl WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/9 XCOCn_GN 411CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE 200201317 <br />APR 2 6 2001 <br />LINCOLN, NEBRASKA HEALTH <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUNL�{SERV IL4t5j'mT1lS!IL;CPD,iurlVlLE <br />VITAL Ansucs <br />CERTIFICATE OF DEATH - 01 04325 <br />1 DECEDENT NAME FIRST MIDDLE LAST <br />2 SEX '.B DATEOFOEATH WooM. Day Yeel <br />Nancy Jean Hu <br />Female April 22, 2001 <br /><. CITY AND BIRTH IILVl USA. remec.OJ Sa. AGE -LaMt BivwA, UNDER YEAR <br />UNDER DAY 6. DATE OF BIRTH IMwM. Day Yaaq <br />Yrs1 5U MON I DAYS <br />Grasland, Nebraska 46 <br />Sc.NOURS MINS 1954 <br />December 29, <br />SOCIAL SEUMBER <br />9a PLACE OF DEATH - <br />HOSPITAL ❑ Inp <br />rod OTHER ❑ Nursing O e <br />507 7757 <br />❑ ER <br />Otyewt ® %R.Yre <br />W FACILITY IHrW inLiart�a}gre sheet ar numCMl <br />170st Anna St. <br />jRR <br />❑ °OA ❑ Oaa,fS°ecYI <br />CITYTOATION OF DEATH <br />M INSIDE CITY LIMITS <br />M COUNTY OF DEATH <br />GrIsland <br />Y. ❑X Na <br />Hall <br />qa RESIDEN <br />9E COUNTY <br />d, CITY. TOWN OR LOCATION <br />90. STREETANDNUMBER pnCWgZVCWe) <br />NSIDE CRY LIMIT$ <br />Nebr <br />Hall <br />Grand Island <br />1703 West Anna St. 6880 <br />Y. X❑ NO ❑ <br />10. RACE leg.. Wla. An4rwan Wian. <br />11,ANCESTRYIeg.. aalian. Mev¢an. German. eld <br />4. ®MARRIED <br />El WIDOWED <br />13. NAME OF SPOUSE IH.'a 0. maiden name! <br />ekl lsP dyl <br />White <br />(SPaPNI <br />American <br />NEVEfl <br />DIVORCED <br />Greg Hu <br />8 PP <br />1DlATE- <br />k LA <br />X 6: 10am <br />R <br />14a. USUALOCCUPATION IGrva aiMdawk ddle dwmg most <br />141 KIND OF BUSINESS INDUSTRY <br />M <br />15. EF UUCATION <br />(SFKEay Mly K9taet9adecdoMebdl <br />j[t�ld rage -121 Colette Ha 5 -I <br />dxer4wg iAe. even ilrelaM) <br />Homemaker <br />Domestic <br />° � § <br />16. FATHER -NAME 1.51 MIDDLE CAST <br />17. MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Ral h Carl uandt <br />Jean <br />Ardith Barnholdt <br />18. WAS DECEASED EVER IN US. ARMED FORCES? <br />19a. INFORMANT -NAME <br />ISi nawre am Tn[el le <br />[Yes. ro. m OIIF. III yes. give wer aN Bares d semce t <br />a HAS ORGAN OR TISSUE DONATION BEENCONSIDEREDI <br />X b WAS CONSENTGRANTED1 <br />No -- - - - - -- <br />Gre Hu <br />} ❑ YES ® NO <br />1% INFORMANT MAILING ADDRESS ISTREET OR R F D. NO.. CITY OR TOWN. STATE. ZIPI <br />Dr. Ryan Crouch, M.D. <br />170 Ann St Grand Island, Nebraska 68803 <br />320 DATE FILED BYF"RA MrY7001 <br />. MER - SIGNAT E LIC 5 O <br />21a. METHDOGF0DISPO5ITION <br />211. DATE <br />21c. CEMETERY OR CREMATORY NAME <br />y <br />©Bdlel ❑Remval <br />Aril <br />26 2001 <br />Wie ert Cemetery <br />.F UNERAL E- AME <br />fna <br />210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin ston- Sondermann F.H. <br />❑ "ems" ❑oald <br />Grand Island, Nebraska <br />221 FUNERAL HOME ADDRESS (STREETORRF.D. NO CITYORTOWN. STATE.ZIPI <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23 IMMEDIATE CAUSE [ENTER ONLY ONE CAUSE PER LINE FOR IM 1Id. AND (C)l I� Ime <br />CeNreen WSMY1 Wam <br />A ELF <br />�111,. 1 /• <br />I I RAJ `W�1 C.� \ �SXA� -. <br />mERry yc, <br />DUE TO. OR AS A COrv5E0UENCE OF <br />Inte va <br />� A ll CD y v h� C.Aat��c4(� <br />m <br />DUE TO. OR AS A CONSEOUENCE CF U <br />`OTHER SIGNIFICANT CONDITIONS- CCdaons conFdNlg to me death CN NX related PART <br />III IF FEMAIf. WAS THERE A <br />2< AUTOPSY 25. WAS CASE REFERRED TO MEgGAL <br />PART PEGNANOYINTNE <br />PA513MONTH$? <br />.I'EXAMINER OR CORONER' <br />[Ages 10SAI Yes No <br />Yes Na Yee NO <br />Me <br />261 DATE OF INU IMO.. Day YrI <br />2K. HOUROFIWURY <br />2fid. DESCRIBE HOW INJURY OCCURRED <br />A..d.M ❑ UMelerm ad <br />M <br />SY1.da PeMmg <br />26e INJURY AT WORK <br />261 PIAeEOF INJURY -A 919, farm. greet ACldy <br />AS LOCATION STREET OR R F. D. NO. CITY OR TOWN STATE <br />H.Xle Inveslgmon <br />Yea ❑ No ❑ <br />olf <br />27a. DATE OF DEATH 1W Day GO <br />28a DATE SIGNED IM, Day. YrI <br />2B1 TIME OF DEATH <br />" April 22,2001 <br />M <br />>4 <br />s<w <br />271. SIIGNED IAA. Day Yrl <br />27c. TIMEa DEATH <br />20c. PRONOUNCED DEAD IM, .. DJN YC) <br />26 d. PRONOUNCED DEAD lM,ul <br />oC <br />1DlATE- <br />k LA <br />X 6: 10am <br />i:� <br />M <br />M <br />E <br />27d. To t11e Meet y Fn0 'kA OeaM acu 1Pe Nre. d and pace aM., <br />° � § <br />2Be. OO. Ce a M eaamina..n aM'w Y.gal4n m my opnion Beam occurred at <br />~ <br />Q1 <br />ceysa M staled <br />° <br />tM Lure, dale aW dace and due 1. Me c,ILA d stalad. <br />IS, nawre arM TnIeI t <br />ISi nawre am Tn[el le <br />29. DIDT08ACCOUSECONTRIBUTE OT DEATH? <br />a HAS ORGAN OR TISSUE DONATION BEENCONSIDEREDI <br />X b WAS CONSENTGRANTED1 <br />.r YES ❑ ND ❑ UNKNOWN <br />.r ❑ YES ® NO <br />} ❑ YES ® NO <br />31 A,f AME AND ADDRESS OF CERTIFIER PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY[ ",Pad Pnml <br />Dr. Ryan Crouch, M.D. <br />32a REGISTRAR <br />320 DATE FILED BYF"RA MrY7001 <br />