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Rev. 1197 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES RNAME AND SUPPORT <br />VRAL STATISM 200206676 <br />FIRST r00LE LAST — - — _ _ <br />J. lAbml Ory YeH <br />1. MCEMNT .NAME <br />George William Peterson 4, 2000 <br />;;;; EE <br />A CITY AND STATEDBIRTH /Amfh USA..nrN aKxa71 S,. AGE LW —04 UNDER UNDERIVEAR H RAKIw WY rI <br />rvM179 SL. MOS.i D.YS MS. 21, 1901 <br />Spalding, Nebraska <br />]. SOCIAL SECIMTW NUMBER r. PUCE OP DEATH <br />� IroMMM OTHER: E] Nara HprlF <br />HOSM_ TA <br />507 -14 -8097 ® R„Ir„�, <br />EROuaeWM <br />N FACILITY. Nem. /pidnetil4Tp'4 p✓s AhrleM mMMeI/ <br />� OD" ❑ a.Iw rsatXrl <br />2203 S. August <br />r <br />Bt CITY TOWNOLCCATXXI OF DEATH r. INSIDE CRY LXAITS r C TY OF MATH <br />Grand Island. Y. ® Ne ❑ Hall <br />BU COUNTY 9e CITY, TOWNORLOCATION W STREETANDMIMBER /AKAFArD1.DC,del r INSIDE CITY LM9IS <br />N. RESIDENCE. STATE <br />Hall Grand Island 2203 S. August 68801 Yr ®� ❑ <br />Nebraska <br />10 RACE- Ie9.WNM. BI•t, Amma,e,Men. 11.ANCESTRYIe9.IMAen. Mmlcr, O.rmr. eel t2. ®AM11 ❑WIDOWED 13 . NNAIMEOFSPOOM /XM9rve M.Me—1 <br />acl'Swell ISP¢MI NEVER DIVORCED Ella Mae .Clark <br />White American <br />1N. USIIM OCCUPATKKN /DAe FHUaxere Corr A.YrM^Nw 1.0. KINOO BUSME95MOUSTRY 15. EOUCATpN (SP%*w0V M21WN EdTpeNR <br />~MBft'.ff a W �raeY 10.121 COr9, II <br />Bulk Plant Mane er Petroleum 1 <br />FIRST MIDDLE LAST I? MOTHER FIRST MIDOLE MAIDEN SURNAME <br />IB. FATHER -NAME - <br />' Au ust M. Peterson Ina Pearl Dallegge <br />• <br />10. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />Ir. INF010.UNf -NAME <br />rv.e. ro' a Mw.l Ix Yee prosww,m aan a rWkeel <br />Yes WWII 10 -25- 1942/11 -13 -19 <br />5Ella Mae Peterson <br />190 INFORMANT MAID— ADDRESS ISTREET qI R1- ND.. CRY OU TOWN. STATE. 2M1 <br />2203 at, Grand Island, NE 68801 <br />20 E R.SN3NATUPE 21 e. MEi1M]DO d5PO31TXIN 21e DATE 21c. CEMETERY OR CREMATORY.NAME <br />®IMatl ❑RwBV.N June 17, _2000 Westlawn Memorial Park <br />y <br />22, . FUNERAL AME 21e. CENETERYORCREMATORYLOCATKIN CITY OR TOWN STATE <br />Li vin ston- Sondermann F.H. E]fnni°°" E)° Grand Island Nebraska <br />M FUNERAL HOME ADDRES6 (STREET OR RF D. NO DRY CR TORN. STATE, M <br />6 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />2B ATE CAUSE TENTER ONLY ONE CAUSE PER LINE FOR lel. 11X. AND fell l i ,.wvM erw.naNw em Mam <br />M <br />vI ' • I �f zVe <br />I I <br />IBM <br />SA COHSE ENCE O'. ,MrrM 9elwe.n saw em rNn <br />I <br />1 <br />rol ' <br />OIIE TO. OR AS kPSE NCE O -. FM.Y Oe11FSenalew r5seem <br />1 <br />Itl ,1 <br />OTHER SIGNIFICANT CONDITIONS- CatlBwN CdIKIaW19a11M ram bul nol rt4at PART W OF WAS T3 NICU 24 AUTOPSY 25 W ER WFERREED <br />X OR <br />Y`N THE ,YEXAMMER <br />PART PPEGNANCYIN THE PASTJMOMHS? <br />F (Arpe 10N1 Y. No Yr NO Yr <br />28e. <br />2B b. DATE O INJURY (M1b. Dry. W/ <br />25 c. HOUR O MIURY 280. DESCRIBE HOW INJURY OCCURRED <br />0 AtckMa ❑ Uaaarm <br />M <br />Sv:citle ❑ FentNrg <br />28B. INJURY AT WORK <br />281.%ACE DFINJUPY.AIM➢M. Term. shoal: N <br />l�t•Y� <br />299. LOCATION STREETORRFO. NO. CITYORTOVIA, STATE...... <br />IlaMdee IMmNg~ <br />Ym❑ Nt <br />011ce RMIaN <br />27.. DATE DF OEATH 1W D.Y Ytl <br />2M. DATE WNED /Aa. Oft a.) <br />280 TONE DF MATH <br />June 14,2000 <br />M , <br />-- <br />a <br />} <br />y <br />27U DATE SIGNED Ma. D,Y YiI <br />2 > TINE OF DEATH <br />2BC PRONOUNCED DEAD /W Dry. W/ <br />M. PRONOUNCED MAD ~1 <br />3F <br />June 000 <br />7:30 pin M <br />1y <br />M <br />s <br />" <br />38 <br />n <br />27a. To pa MM NMwwl.a .M caret n aMe.m pero ems. a,w <br />29e. OnM IwNdMwanMan wM -a nWwgMbn.amyoµv: r.m axwn9w <br />X celnelnl <br />88 <br />n. Mm.M Ma qAt. me awa9rcwRNq PYMC. <br />,m T <br />n q0 TOBACCO UBE THE DEATH? r <br />JOe HAS ORGAN OR TISSUE DONATICN BEEN CON91MRE0? <br />X.b WAS CONSENT GRANTED? <br />Y YES NO NKNOWN <br />k YES NO <br />YES NO _ <br />JI Hass .lxlA OCERTKIFA 'WAR.CORONERS PHYSKX4N OR COUNTY ATTORNEY' /T <br />k Dr. John A. Wagoner, M.D., 800 Alpha St., Grand Island, NE 68803 <br />Jb. RE05TRAR <br />J2e DATE FRED BY REGISTRAR l.a. Dry I'll <br />FOR VITAL STATISTICS USE ONLY <br />Place....................... A... ............................. B .......... .... .................. C ............................... : D ................................ E ...................... .......... part II.............. _...: TMV ......... ........ <br />NSC............. ............................... ...... ....................... ............. I..... ...... ............................... -- .... ... --........................................ ............................... Census Tract No <br />Work.......................... ....... ....... - ........................ ............ ........................................................................................................................................... ............................... . <br />LIC ....................... ...... .............. ... .... ....................... . ...... .......... ... ......... ..... .............................. . ........... . ............... <br />...................................................... ............................... <br />Reject..........._ ....................................................................... .............................._ .............. ..... ............................. ................ <br />I hereby certify this to be a true and correct copy of the original <br />"4fi'ed �vith the State of Nebraska <br />- *w7p``''� q III GENERgI NOTARY -State of Nebraska <br />by _yl�( TERRY L LOS HEN <br />My Comm. Exp. :2-c>.Z <br />Signed in m this of <br />f Notary Public <br />