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Rev. I I f97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS 200208458 <br />f F.RTTFTr ATP ()F TWATH <br />d <br />G <br />O <br />IO <br />U <br />T <br />C <br />0 <br />U <br />W 1 0 <br />E <br />d <br />U <br />Z m <br />Z <br />w E Lu C - <br />w fO <br />C) <br />Ld D <br />Or <br />w n <br />O a <br />cW N <br />C W <br />J <br />Z O <br />Z LL <br />M <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at (b). AND Ill <br />PART <br />/yl / W <br />Dal u TY/l.(A l ((.C} <br />M) <br />(c) <br />mm val ann n aaa ant dam <br />between wus aN dam <br />OTHER SIGNIFICANT CONDITIONS- Camditiona conMbnkq M Me death but lwl related <br />PART <br />II QbtAiut &MV0I I <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (UOM Day Yew) <br />M DATE a INJURY pee.. Day. YrJ <br />Maxine Leeree Drevsen <br />Female <br />January 18, 2000 <br />O. CITY AND STATE OF BIRTH (Moth USA.. n. cd w" <br />5. AGE Lee Eddy I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16, DATE OF BIRTH ~0. Day. Year) <br />5b MDR. l wY5 <br />$a HouRS; MI 5 <br />Stromsburg, Nebraska <br />"N' 77 <br />February 24, 1922 <br />T. SOCIAL SECURTIY NUMBER <br />Be . PLACE OF DEATH <br />507 -36 -1549 <br />HOSPITAL ® Ir,aiM* OTHER ❑ N.,v, Home <br />M <br />❑ ER Otnadnl ❑ Resters. <br />8b. FACILITY - Name (M rwl nt dbM1 give shad antlmalldTJ <br />St. Francis Medical Center <br />❑ DOA ❑ OverlsP.aWI <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />ad INSIDECITYLIMITS <br />He COUNTY OF DEATH <br />Grand Island <br />Y. ❑X Nd ❑ <br />Hall <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />9a RESIDENCE - STATE <br />9b COUNTY <br />9c. CRY,TOWNOHLOCAT*N <br />9d. STREETANDNUMSER flrcNdM Z,P CWeI <br />9e. INSIDE CRY LIMITS <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER 'SPHYSICANORCWNTYATORNEYI (Typed PiMB <br />Nebraska <br />Hall <br />Grand Island <br />504 E. 10th 68801 <br />Yes N. ❑ <br />ID . PACE -(a 9. WMIe. B%cN. AmerlcanlMan. <br />11.ANCESTRY(e.9. Italian. MMKn, German ell <br />12.O MARRIED ❑WIDOWED <br />13. NAMEOFSPOUSE law+k give maitlm nemeJ <br />elc.l lSp.u6' ite <br />WWCC1l <br />ISOecINI American <br />NEVER DWORCED <br />A R <br />Delmar L. Drevsen <br />Ida. USUALOCCUPATION fGivaketddwakdWadVrft MddI <br />tab KIND OFBUENESS INDUSTRY <br />15. EDUCATION ($WIN ONVIrVa.lgratec r"eIet) <br />Elememary eMwy m lE LONepe ll <br />g° <br />dwra Me. KredMl <br />asiiier <br />Grocery Store <br />15, FIMT MIDDE UST <br />1? MOTHER FIRST MIDDLE MAIDEN SURNAME <br />William H. Grobe <br />Hazel Unknown <br />fa D EVER IN U5. MMED FORCE5T <br />19a. INFORMANT -NAME <br />Illyea.gwewwaNdbede.MC.. <br />Delmar L. Drevsen <br />LNMEFIMT <br />190MAILING AOORESS (STREET ORRFO.Np..CRY OR TOWN. STATE 21P1 <br />10th, Grand Island, Nebraska 68801 <br />IGNATURE B UCENSE NO 93/ <br />21e. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY NAME <br />®Buried ❑R.m.v.I <br />Jan. 20, 2000 <br />Westlawn Memorial Park <br />a FUNEFNL OW -NAME <br />21E. CEMETERYORCREMATORYLOCATION CITY OR TOWN STATE <br />Apfel - Butler- Geddes <br />❑L.w ❑ �IrW <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR RF.D. NO. CRY OR TOWN. STATE, 2IPI <br />1123 West Second, Grand Island, NE 68801 <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at (b). AND Ill <br />PART <br />/yl / W <br />Dal u TY/l.(A l ((.C} <br />M) <br />(c) <br />mm val ann n aaa ant dam <br />between wus aN dam <br />OTHER SIGNIFICANT CONDITIONS- Camditiona conMbnkq M Me death but lwl related <br />PART <br />II QbtAiut &MV0I I <br />PART IN IF FEMALE WAS THERE <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10-541 YN NO <br />24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Year NO YM NO Ll <br />26a. <br />M DATE a INJURY pee.. Day. YrJ <br />2C. HOUR OF INJURY 25d. DESCRIBE HOW INJURY OCCURRED <br />A..Idn1 F UNeRrminetl <br />M <br />❑ SUidb. I] Pander) <br />HOmicld Invead,.I. <br />28.. INJURY AT WORK <br />Yee ❑ NO ❑ <br />pu OO (���� qOmnn <br />281. WALE ib INJURY ppeoyy/ farm. Neel Wor, <br />M' <br />269. LOCATION STREET OR RF O. NO. CITY OR TOWN STATE <br />2 7a DATE OF DEATH (ft. Day. Y) <br />2Ba. DATE SIGNED (Md. Day Yf I <br />29b. TIME OF DEATH <br />9; <br />#$j <br />l- 18- ao(% <br />� } <br />u <br />M <br />DATE SIGNED (ADO.. Dey Yr) <br />ITC TIME OF DEATH n <br />J� (� <br />�V <br />g2Tb <br />20c. PRONOUNCED DEAD IAffi. Day Y4 <br />2W PRONOUNCEDDEAD (Howl <br />M <br />27U. TO Me bea of M <br />my OYAet9e. tleedb ¢cwred el Ma pee, dale IN One Wtlue I. me <br />2B.. OnlM baziadeaaminedm aNlbr num9gBdn. in my apnid tlBBN xNrred at <br />causel s fSi reireal /N/"� <br />a <br />IlI6IInw, dle wb plBCe Yb Wa 101re rausN.I MaMtl. <br />(Sicaft. aN Trial I. <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONBIDEREDI <br />30.e WAS CONSENT GRANTED? <br />El YES CkNO 11 UNKNOWN <br />El YES YES NO <br />F <br />❑ YES / -y NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER 'SPHYSICANORCWNTYATORNEYI (Typed PiMB <br />Ann K. Morse, M.D. 729 N. Custer, Grand Island, NE 68803 <br />32a, REGISTRAR <br />32b DATE FILED BY REGISTRAR IW. Day. Y,I <br />FOR VITAL STATISTICS USE ONLY <br />Place................... .... A ................................ B..................... <br />NS C ....................................................... ............................... <br />Reject <br />. A <br />.... ............................Part II ...................... TMV........................... <br />.............. ............................... .........................Census Tract No. <br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE <br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. <br />EEL -B LER- GEDDES FUN HOME <br />