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<br />WHEN THIS COPY CARDS TFE RAISED WL OF THE NEBRASKA HEALTH A
<br />SYSTEM, IT CERTIFIIES THE BELOW TO Wk TRUE COPY OF THE ORIGINAL RECQ9
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DA JUISSUANCE 200-20 � $ 97 fC
<br />2 5 2001
<br />A
<br />LINCOLN, NEBRASKA HEAD App " _
<br />STATE OF NEBRASKA- DEPARTMENT OF MALM AND HRAMI V SK 4
<br />YKrAL STATTSTTCS
<br />rpm tiviraTFnKr ni"aTtJ
<br />_ -�
<br />X6724
<br />I DE(0EN7 -NAME FIRST
<br />MIDDLE LAST -
<br />? SEX
<br />�3 DATE OF DEATH Mnrun. Day Year)
<br />rrf
<br />Male
<br />CZ;
<br />N
<br />�l 4M
<br />C31
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH (Month. Day Year)
<br />5b MOS DAYS
<br />5c HOURS MINS
<br />Griswold, Iowa
<br />IYrs
<br />70
<br />mt
<br />7 SOCIAL SECURTIY NUMBER
<br />Yea No
<br />❑ ❑
<br />n
<br />-c
<br />o
<br />O
<br />HOSPITAL ❑ Inpareal OTHER ❑ Nursing Home
<br />June 19, 2001 8:25 am
<br />AC PRONOUNCED DEAD
<br />y
<br />Ea
<br />i
<br />p -n
<br />O
<br />St. Francis Medical Center
<br />27d To the best of my k1owle1gt, death occurred at the time dale and DlaGe and due IC the
<br />causelsl stated
<br />❑ DOA ❑ Other /$peClyt
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />the Irme. date a ace dpR� to the 2usetsl stated
<br />ISr nature and Trtle /\ Hall Co Atty
<br />8d INSIDE CITY LIMITS A@ COUNTY OF DEATH
<br />rn
<br />lb—WAS
<br />❑ YES ❑ NO ® 'UNKNOWN ❑ YES NO ❑ YES NO
<br />A a)
<br />O
<br />Jerom E Janulewicz, Hall Co linty A;torney,
<br />9c. CITY. TOWN OR LOCATION' -
<br />11 STREET AND NUMBER J#kc6dhg Lp Codbl 9e kISIDE CITY {,f ,,I,
<br />Nebraska Hall
<br />32b DATE FILED BY REGISTRAR IMo. Day. Yr)
<br />Grand Island
<br />2507 Pioneer Blvd, 68801 Yea 0 No ❑
<br />10 RACE - (e g.. White Black American Indian
<br />11. ANCESTRY Ie.g..
<br />Italian. Mexican, German, etc1
<br />t2. ® MARRIED
<br />❑ WIDOWED
<br />13 NAME OF SPOUSE df wrfe give maiden name)
<br />ete.l tSa&okYI
<br />White
<br />(Spec�ryl
<br />I
<br />American
<br />NEVER
<br />MARR
<br />CAD
<br />M. Joann Cartano
<br />1
<br />. USUAL OCCUPATION )G,ve kind of work done during most
<br />of workmglde. even drNnedl
<br />tab KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION )Spec dy only highest grade completed)
<br />Elementary or Secondary (0 12) College 11 a 0, 5-t
<br />12 5
<br />Salesman
<br />[1.4'
<br />A
<br />6 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />WHEN THIS COPY CARDS TFE RAISED WL OF THE NEBRASKA HEALTH A
<br />SYSTEM, IT CERTIFIIES THE BELOW TO Wk TRUE COPY OF THE ORIGINAL RECQ9
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DA JUISSUANCE 200-20 � $ 97 fC
<br />2 5 2001
<br />A
<br />LINCOLN, NEBRASKA HEAD App " _
<br />STATE OF NEBRASKA- DEPARTMENT OF MALM AND HRAMI V SK 4
<br />YKrAL STATTSTTCS
<br />rpm tiviraTFnKr ni"aTtJ
<br />_ -�
<br />X6724
<br />I DE(0EN7 -NAME FIRST
<br />MIDDLE LAST -
<br />? SEX
<br />�3 DATE OF DEATH Mnrun. Day Year)
<br />Forrest Hubert Houser
<br />Male
<br />June 16, 2001
<br />1 CITY AND STATE OF BIRTH ilf notm US.A.. name count y)
<br />L -
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH (Month. Day Year)
<br />5b MOS DAYS
<br />5c HOURS MINS
<br />Griswold, Iowa
<br />IYrs
<br />70
<br />February 4, 1931
<br />7 SOCIAL SECURTIY NUMBER
<br />Yea No
<br />❑ ❑
<br />8a PLACE OF DEATH
<br />481 -30 -0365
<br />2�a DATE SIGNED rMC Day Yr I 28b TIME OF DEATH
<br />HOSPITAL ❑ Inpareal OTHER ❑ Nursing Home
<br />June 19, 2001 8:25 am
<br />AC PRONOUNCED DEAD
<br />y
<br />Ea
<br />i
<br />a ER Outpatient ❑ Residence
<br />8b FACILITY - Name (If not ,nsfONion, give street and number)
<br />St. Francis Medical Center
<br />27d To the best of my k1owle1gt, death occurred at the time dale and DlaGe and due IC the
<br />causelsl stated
<br />❑ DOA ❑ Other /$peClyt
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />the Irme. date a ace dpR� to the 2usetsl stated
<br />ISr nature and Trtle /\ Hall Co Atty
<br />8d INSIDE CITY LIMITS A@ COUNTY OF DEATH
<br />Grand Island`
<br />lb—WAS
<br />❑ YES ❑ NO ® 'UNKNOWN ❑ YES NO ❑ YES NO
<br />�+
<br />9a RESIDENCE - STATE 9b COUNTY
<br />Jerom E Janulewicz, Hall Co linty A;torney,
<br />9c. CITY. TOWN OR LOCATION' -
<br />11 STREET AND NUMBER J#kc6dhg Lp Codbl 9e kISIDE CITY {,f ,,I,
<br />Nebraska Hall
<br />32b DATE FILED BY REGISTRAR IMo. Day. Yr)
<br />Grand Island
<br />2507 Pioneer Blvd, 68801 Yea 0 No ❑
<br />10 RACE - (e g.. White Black American Indian
<br />11. ANCESTRY Ie.g..
<br />Italian. Mexican, German, etc1
<br />t2. ® MARRIED
<br />❑ WIDOWED
<br />13 NAME OF SPOUSE df wrfe give maiden name)
<br />ete.l tSa&okYI
<br />White
<br />(Spec�ryl
<br />I
<br />American
<br />NEVER
<br />MARR
<br />DIVORCED
<br />M. Joann Cartano
<br />1
<br />. USUAL OCCUPATION )G,ve kind of work done during most
<br />of workmglde. even drNnedl
<br />tab KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION )Spec dy only highest grade completed)
<br />Elementary or Secondary (0 12) College 11 a 0, 5-t
<br />12 5
<br />Salesman
<br />[1.4'
<br />A
<br />6 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Lyle V.
<br />Houser
<br />Marie B. McCormick
<br />WAS DECEASED EVER IN US. ARMED FORCES?
<br />- -11s INFORMANT NAME
<br />IYes n o or unk I !II yes. q,ve war aryl dares 01 servlc/3)
<br />-
<br />Yes Army, 1956 to 1958
<br />M. ,loan€* .H"!! rn ,
<br />l9b INFORMANT MAILING ADDRESS ISTREET OR FILE D NO., CITY OR TOWN. STATE. ZIP)'
<br />`
<br />2507 Pioneer Blvd., Grand
<br />Island, NE 68801
<br />20 EMBALMER - SIGNA R 8 Ll ENO
<br />21 a. METHOD OF DISPOSITION
<br />21D. DATE
<br />21C
<br />CEMETERY OR CREMATORY - NAME
<br />BW141 Rertgval
<br />❑
<br />June 20,
<br />2001 Grand
<br />Island City Cemetery
<br />224-l'UNIETIAL HOIv - AME
<br />21d CEMETERY
<br />OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />❑Cremation ❑Donatlhn
<br />Grand Island Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY
<br />OR TOWN. STATE, ZIP)
<br />601 North Webb Road, Grand
<br />Island, NE 68803 -4050
<br />PART , �A Interval between onset and dean
<br />lal
<br />Natural causes unknown
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />Ibl " I.
<br />DUE TO OR AS A CONSEQUENCE IrNerval peNreen on6e1 and Beam
<br />r— OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />PART III IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />WAS CASE REFERRED TO MEDICAL
<br />j II
<br />PREGNANCY IN Ti E PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />L -
<br />(Ages 10041 Yes No
<br />Yes No
<br />Pq
<br />Yes ® No ❑
<br />26a
<br />M, DATE OF INJURY IMo Day Yri 26c HOUR OF INJURY
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />M
<br />'� cd JI Pr g
<br />I —
<br />26e
<br />26e INJURY AT WORK .261 PLACE OF INJURY Al hone fa•m slreel factory
<br />office bwltlmg etc lSOecdy/
<br />T2 STREET OR RFD NO CITY OR TOWN STATE
<br />rlamiade Invesugauon
<br />Yea No
<br />❑ ❑
<br />T 27a DATE OF DEATH rM, Day. Yr)
<br />2�a DATE SIGNED rMC Day Yr I 28b TIME OF DEATH
<br />n I 27b DATE SIGNED IMo. Day Yr 27c TIME OF DEATH
<br />June 19, 2001 8:25 am
<br />AC PRONOUNCED DEAD
<br />y
<br />Ea
<br />i
<br />(Mo.. Day, Yr) PRONOUNCED DEAD (Hour)
<br />3 C)
<br />June 1 2001
<br />s M
<br />x:25 am M
<br />27d To the best of my k1owle1gt, death occurred at the time dale and DlaGe and due IC the
<br />causelsl stated
<br />g On the bans of e a indtiOn an r ioveamgation, m my opinion death occurred at
<br />(S, naure and Tale) ►
<br />the Irme. date a ace dpR� to the 2usetsl stated
<br />ISr nature and Trtle /\ Hall Co Atty
<br />3@ DID TOBACCO USE CONTRIBUTE TO THE DEATH? a HAS ORGAN OR TISSUE
<br />DONATION BEEN CONSIDERED? -- CO ENT GRANTED'
<br />lb—WAS
<br />❑ YES ❑ NO ® 'UNKNOWN ❑ YES NO ❑ YES NO
<br />NAME AND ADDRIE53 3F_ CERTIFIER IPHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY
<br />Type or Pr(ht)
<br />Jerom E Janulewicz, Hall Co linty A;torney,
<br />117 E lst, Grand Island, NE
<br />32a REGISTRAR A
<br />32b DATE FILED BY REGISTRAR IMo. Day. Yr)
<br />_ _ 7
<br />,�t.
<br />JUN 2 2 2001
<br />U
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