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Rev 11197 - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE! fl" @ 8
<br />VITAL STATIMICS UU uu 5
<br />CFRTTFTCATF. OF fIF.ATH
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<br />FOR VITAL STATISTICS USE ONLY
<br />Place....................... A................................ B................................ C................................ D...... ..........................E.... ............................Part II..................... .TMV...........................
<br />NSC................................................................ ............................... .Census Tract No.
<br />. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
<br />Work............................_....................._...._..........._......_ _..__..____._.__......____.._..
<br />Reject
<br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE
<br />FILED WITH THE BUREAU OF VITALS ISTICS IN LINCOLN, NEBRASKA.
<br />FEL -BUT ER- GEODES FUN HOME
<br />1. DECEDENT - NAME FIRST MIDDLE UST
<br />2. SEX
<br />3. DATE OF DEATH OWMIh NY, ✓MMI
<br />Delmar Leroy Drevsen
<br />Male
<br />May 1, 2002
<br />p, CITY AND STATE OF BIRTH IffccuO USA.. Remecdmayl
<br />Se. AGE - Las18nfiday I
<br />UNDER I YEAR
<br />UNOT I OAY
<br />6. DATE OF BIRTH (Md NY Yeay
<br />Kennard, Nebraska
<br />Wul 94
<br />5a Mos.: DAYS
<br />Sc NOD",
<br />July 17, 1907
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />45 2- 1 0 -39 20
<br />HOSPITAL ❑ Inputted OTHER ® NA,mg Home
<br />❑ ER OuMM1Nnd ❑ ReRderce
<br />8, FACILITY -Name IN MI moubsock, give NTBW and A' low
<br />Wedgewood Nursing Care Center
<br />❑ DOA ❑ Me, Isoacn"
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Ye, ® Np ❑
<br />Hall
<br />9a. RESIDENCE STATE
<br />9b. COUNTY
<br />gc. CITY. TOWN OR LOCATION
<br />9d. STREETANDNUMBER y0k1ob,g wCoded
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />800 Stoeger Dr. 68803
<br />Yee © w ❑
<br />IO RACE- Iag..Wbee. Black. A."con Inches.
<br />11. ANCESTRY lug- Mahan, Me,IcaM Gennen, alcl
<br />12. ❑MARRIED ®WIDOWED
<br />13. NAMEOFSPOUSE (nelwgn,emaieeniwmel
<br />elG(Spec"'I White
<br />15wdyl Danish
<br />NEVER DIVORCED
<br />MARRIE
<br />Maxine L. Grobe
<br />Ida. USUALOCCUPATION (Give AVpd wrvM CMN pWtig m0.,l 1@
<br />HINDCFBUSINESSINDUSTRY
<br />15 EDUCATION
<br />ISpeeilyonly NgMedg.aEecomRebal
<br />EN_M_MT m Secondary 10121 Co., N �A m 5.1
<br />12
<br />d awkmq lRa elerr Aroped!
<br />Owner /Operator
<br />Grocer Store
<br />16. FATHER NAME FIRST MIDDLE UST
<br />I7, MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Henry Drevsen
<br />Anna Jeppesen
<br />19. WAS DECEASED EVER IN US. MIMED FORCES?
<br />tge. INFORMANT NAME
<br />(YesM unk. b m,va.wMMndoae,o1sMwceal
<br />No
<br />Don R an
<br />10 INFORMANT MADNG ADDRESS ISTREET OR R.F. D. NO., CT' OR TOWN. STATE. ZIP)
<br />P.O. Box 985, Grand Island NE. 68801
<br />EMB MER- SIGNATURE B LICENSE NO. p21
<br />e. METHODOFOISPOSTION
<br />21b DATE 21c
<br />CEMETERYOR CREMATORY NAME
<br />®BUmI ❑RemeaI
<br />May 6, 2002
<br />Westlawn Memorial Park
<br />22a. FUNERAL OME -NAME
<br />21d. CEMETERYORCREMATORYLOCATION CRY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑C... ❑DoNdsM
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS (STREET OR RFD. NO.. CRY OR TOWN. STATE ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />A IMMEDIATECAUSE (ENTER ONLY ONE CAUSE PER LINE FOR(at mL AND(cil I IM.Nal baMwn ons,I aM MMII
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<br />OUE TO.OA AG A LONSEOUENCE OFD Merval belwem anpH aM deMb
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<br />PART OTHER SIGNIFICANT CONWTKKVS- CmtlidoeM COnVRUNg to ma team bM mVelAled
<br />PART FEMAILE WAS THEREA 2p.
<br />AUTOPSY
<br />25. CASE TO MEDICAL
<br />I) V��� tl �
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<br />NCYIN TH
<br />PREGNANCY IN THE PAST3 MONTHS?
<br />E %AMINER OR CORONERR
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<br />(Age510S11 Yes NO
<br />Vee '41
<br />Ya6 NO
<br />269.
<br />M. DATEOFINJURY (Ak,,Day. ✓rJ
<br />Z6c.igUROFINJURY M. DESCRIBE HOW INJURY OCCURRED
<br />❑ AccidmM ❑ UMmemlmed
<br />❑ SMnne ❑ Nuohng
<br />269. INJURYATWCR%
<br />261. VC IFINJp AY At Wou, 1um 611BM. laclay
<br />E Itl dyl
<br />26g. LOCATION STREET OR R. F.D. NO. CRYORTOWN STATE
<br />❑ HamcNe IrweslgMwn
<br />Yep ❑ No ❑
<br />aM, STac
<br />279. DATE OF DEATH /Ly. Day Vq
<br />28a. DATE SIGNED /Mo. Dep Vpl
<br />no TIME OF DEATH
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<br />2Tb. DATESIONED ft, Dap YCI
<br />27C. TWEOFDEATH
<br />2BC. PRONOUNCED DEAD Nko.. Dey. Ycy
<br />Zed. PRONOUNCED DEAD ~t
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<br />29 DID TOBACCO USE CONAIT�RIBUTE TO THE DEATH? 30.9
<br />HAS ORGAN OR TISIBLE DONATION�BBEEEEI CONSIDERED, 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES NO ❑ UkMNCWN
<br />/N
<br />❑ YES NO
<br />❑ YES �NO
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<br />(ICI
<br />31, NAME ANDADORESS OF CERTR91 (PHYS)CIA .0 R NERSPMSICANORLDUNTYAMMEY) ITMyed PdWl
<br />Anne K. Morse M.D. 729 N. Custer, Grand Island, NE. 68803
<br />32a, REGISTRAR
<br />Sep DATE FILED BY REGISTRAR (ft, Day. YT)
<br />FOR VITAL STATISTICS USE ONLY
<br />Place....................... A................................ B................................ C................................ D...... ..........................E.... ............................Part II..................... .TMV...........................
<br />NSC................................................................ ............................... .Census Tract No.
<br />. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
<br />Work............................_....................._...._..........._......_ _..__..____._.__......____.._..
<br />Reject
<br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE
<br />FILED WITH THE BUREAU OF VITALS ISTICS IN LINCOLN, NEBRASKA.
<br />FEL -BUT ER- GEODES FUN HOME
<br />
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