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<br />WHEN THIS COPYCWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. O ISSUANCE
<br />IN f 3 Z 0 0' �IA�Nf
<br />LEY S. COOPER
<br />200204319 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />n�
<br />r ')c - '_DENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH ,Month Dav Yeao
<br />Henry Edward Coons
<br />Male
<br />June 1, 2001
<br />4 CITY AND STATE OF BIRTH 4t not m USA name country/
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH :Month. Day Year)
<br />Alma, Nebraska
<br />fYrs
<br />53
<br />5b MOS DAYS
<br />5c. HOURS MINS
<br />July 1, 1947
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />506-60-6441
<br />HOSPITAL ® Inpatient OTHER Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Ob FACILITY - Name ((/not institution, give street anb number)
<br />St. Francis Medical Center
<br />❑ DOA El o, er ispe tv,
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yes ❑ No ❑
<br />m CA
<br />9a RESIDENCE - STATE
<br />COUNTY
<br />rim
<br />9d STREET AND NUMBER (Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Z
<br />Grand Island
<br />235 South Oak 68801
<br />Yes] No ❑
<br />10 RACE - (e g., While. Black American Indian
<br />11. ANCESTRY le g Italian, Mexican. German. etcl
<br />12 ® MARRIED ❑ WIDOWED
<br />i 3 NAME OF SPOUSE /it wile give maiden namel
<br />etc l (Soecityl
<br />White
<br />n
<br />NEVER DIVORCED
<br />EMAIRRIED
<br />Linda S. Dexter
<br />co
<br />14a USUAL OCCUPATION /Give kind of work done during most 14b
<br />I
<br />KIND OF BUSINESS INDUSTRY
<br />N
<br />� �
<br />o C:L
<br />Elementar or Secondary 10.121 College 11 -4 or 5 +
<br />12
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Maxwell Hargus Coons
<br />Reti Delores Holley
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME
<br />119a
<br />Yes. no or unk.) Ilf yes g+ w a dal sot rvice
<br />ies Vie nam � -'L - b5��1-63 -69 ' Linda S. Coons
<br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO CITY OR TOWN STATE ZIP)
<br />235 South Oak Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21 a METHOD OF DISPOSITION
<br />+ 21b DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑ Buhal ❑ Removal
<br />June 2, 2001 Central
<br />NE Cremation Servi(
<br />22a FUNERAL HOME -NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />® Cremation ❑ Donauor
<br />Gibbon, Nebraska
<br />C)
<br />0
<br />23, IMMEDIATE CAU E (ENTER ONLY NE CAUSE PER LINE FOR fal (b). AND (cl) Interval between onset and deal^
<br />PART
<br />I
<br />'i
<br />lal try
<br />I --- --- !k�R�
<br />DUE TO, OR AS A CONSEOU NCE OF Interval between onset and dean
<br />aMp
<br />(b) c _
<br />DUE TO OR AS A CONSEQUEN E OF intervar between onset and cleat,
<br />C:) C003I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS)
<br />II
<br />EXAMINER OR CORONER'i
<br />Cr1
<br />�
<br />Yes No
<br />26a
<br />26b DATE OF INJURY r;Mo Day Yr)
<br />26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />i
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<br />26e INJURY AT WORK
<br />26f PACE OF INJURY -At home Ia+rn street lactory
<br />26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />r
<br />3
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<br />28b TIME OF DEATH
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<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD IMo Day, Yrl
<br />28d. PRONOUNCED DEAD (Hour
<br />>-
<br />g 4
<br />M
<br />z 0
<br />C.n
<br />..y
<br />27d To the best of my knowledge. death occu red t the time date and place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />2 a
<br />2 Q °
<br />causelsl stated / I
<br />I
<br />cn
<br />CA, t
<br />(
<br />iS+ nature and Title) ► '�^
<br />(Signature and Title) 0
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30
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<br />WHEN THIS COPYCWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. O ISSUANCE
<br />IN f 3 Z 0 0' �IA�Nf
<br />LEY S. COOPER
<br />200204319 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />n�
<br />r ')c - '_DENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH ,Month Dav Yeao
<br />Henry Edward Coons
<br />Male
<br />June 1, 2001
<br />4 CITY AND STATE OF BIRTH 4t not m USA name country/
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH :Month. Day Year)
<br />Alma, Nebraska
<br />fYrs
<br />53
<br />5b MOS DAYS
<br />5c. HOURS MINS
<br />July 1, 1947
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />506-60-6441
<br />HOSPITAL ® Inpatient OTHER Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Ob FACILITY - Name ((/not institution, give street anb number)
<br />St. Francis Medical Center
<br />❑ DOA El o, er ispe tv,
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yes ❑ No ❑
<br />Hall
<br />9a RESIDENCE - STATE
<br />COUNTY
<br />9c. CITY- TOWN OR LOCATION
<br />9d STREET AND NUMBER (Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />19b
<br />Hall
<br />Grand Island
<br />235 South Oak 68801
<br />Yes] No ❑
<br />10 RACE - (e g., While. Black American Indian
<br />11. ANCESTRY le g Italian, Mexican. German. etcl
<br />12 ® MARRIED ❑ WIDOWED
<br />i 3 NAME OF SPOUSE /it wile give maiden namel
<br />etc l (Soecityl
<br />White
<br />ISpec+tyl
<br />American
<br />NEVER DIVORCED
<br />EMAIRRIED
<br />Linda S. Dexter
<br />14a USUAL OCCUPATION /Give kind of work done during most 14b
<br />I
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completed)
<br />of working life. even it retired
<br />Shop Supervisor
<br />Rich & Sons Cam er Sales
<br />Elementar or Secondary 10.121 College 11 -4 or 5 +
<br />12
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Maxwell Hargus Coons
<br />Reti Delores Holley
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME
<br />119a
<br />Yes. no or unk.) Ilf yes g+ w a dal sot rvice
<br />ies Vie nam � -'L - b5��1-63 -69 ' Linda S. Coons
<br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO CITY OR TOWN STATE ZIP)
<br />235 South Oak Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21 a METHOD OF DISPOSITION
<br />+ 21b DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑ Buhal ❑ Removal
<br />June 2, 2001 Central
<br />NE Cremation Servi(
<br />22a FUNERAL HOME -NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />® Cremation ❑ Donauor
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D- NO CITY OR TOWN STATE. ZIP)
<br />1123 West Second Street Grand Island, Nebraska 68801
<br />23, IMMEDIATE CAU E (ENTER ONLY NE CAUSE PER LINE FOR fal (b). AND (cl) Interval between onset and deal^
<br />PART
<br />I
<br />'i
<br />lal try
<br />I --- --- !k�R�
<br />DUE TO, OR AS A CONSEOU NCE OF Interval between onset and dean
<br />L.0 1
<br />(b) c _
<br />DUE TO OR AS A CONSEQUEN E OF intervar between onset and cleat,
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS)
<br />II
<br />EXAMINER OR CORONER'i
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a
<br />26b DATE OF INJURY r;Mo Day Yr)
<br />26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />i
<br />I
<br />❑ Accident ❑ Unoete,m ned f
<br />tit
<br />❑ Suicide ❑ Pend q
<br />26e INJURY AT WORK
<br />26f PACE OF INJURY -At home Ia+rn street lactory
<br />26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />Yes No
<br />office building. etc (Specify)
<br />r27a DATE OF DEATH (Mo Day. Yr.)
<br />28a DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
<br />I oa
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<br />27b DATE SIG ED (Mo. Day Yr)
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD IMo Day, Yrl
<br />28d. PRONOUNCED DEAD (Hour
<br />U ¢ Z O
<br />g 4
<br />M
<br />z 0
<br />M
<br />27d To the best of my knowledge. death occu red t the time date and place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />2 a
<br />2 Q °
<br />causelsl stated / I
<br />I
<br />°
<br />the time, date and place and due to the causelsl staled
<br />(
<br />iS+ nature and Title) ► '�^
<br />(Signature and Title) 0
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED) 30.b
<br />WAS CONSENT GRANTED)
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES -_N0
<br />❑ YES FU4--NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY. Type or Print)
<br />Dr. Sitki Copur 2116 West Fa'dley Ave 68803
<br />32a REGISTRAR
<br />32b DATE FILED BY REGISTRAR „(Mo.. Day Yr)
<br />JUN 7 2001
<br />e
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