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<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANQ J:!f;JIIIMtM!fVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.RKOllDft)iJlFIL"!oW1TH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA n$JICS'-'Sj!eTmN;lNHlCI1-IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "/I','c.Z ~~,,:;_
<br />
<br />
<br />DA;;'"7;3 200510691 ~:"T:>~
<br />LINCOLN, NEBRASKA HEALTH AND ~N.~:a:SY..~
<br />
<br />,. ~- - ~
<br />STATE OF NEBRASKA- DEPARlMENT OF HEALTII AND HUMAN SERV<<iSF~f;t~PORT
<br />VITAL STATISTICS.'S~,' --,.".:co,.--
<br />CERTIFICATE OF DEATH 0 3
<br />
<br />
<br />1 DECEDENT',~NAME
<br />
<br />--'--FIRST
<br />
<br />MIDDLe
<br />
<br />LAST
<br />
<br />2. SeX
<br />
<br />IMonth DilY Year)
<br />
<br />Eugene
<br />
<br />Hoops
<br />
<br />Male
<br />
<br />Herschel
<br />
<br />February 22, 2003
<br />
<br />6. DATE. O~ BIt=llH (Month. Day. Year)
<br />
<br />4. CITy ANO STATE OF BIRTH Ilf not in U.S.A.. rJame country!
<br />
<br />Sa. AGE - Last Birthdav
<br />IY,,' 83
<br />
<br />UNDeR 1 YeAR
<br />5b. MOS DAYS
<br />
<br />UNDER 1 DAY
<br />5e. HOURS MINS
<br />
<br />Springvie.v, Nebraska
<br />7. SOCIAl. SECURTIY NuMBER
<br />
<br />November 1, 1919
<br />
<br /> 8. PLAC" OF DEATH
<br /> HOSPITAL D
<br /> D
<br /> D
<br />8d INSIDE CITY L1MilS
<br />
<br />OOA
<br />
<br />505-16-5520
<br />
<br />Inp21len!
<br />
<br />OTHER ~ NUf~u)g HOlT1fl
<br />
<br />D ReSidence
<br />
<br />D OIMr /508(:1I\'1 ~~~.~
<br />
<br />8b FACILITY - Name
<br />
<br />(If (lot IflSlilution. give stroot anO/lumberl
<br />
<br />ER OUlpalienl
<br />
<br />Grand Island Veterans Hare
<br />
<br />81;: CITY TOWN OFllOCATlON OF DEATH
<br />
<br />
<br />Grand Islam
<br />
<br />9a RESIDENCE, STATE
<br />
<br />
<br />Nesle Kenar
<br />
<br />9d STREET AND NUM8EFl IfnGlvding Zip Codel
<br />
<br />Nebraska
<br />
<br /> ~
<br />(""> (" 3- 0
<br />,J'
<br />CJ .-< .~
<br />c= 1~ N
<br />z .---'
<br />--l it! 3' 0
<br />.~ I c::>
<br />0 -~
<br />'."\ U1
<br /> ;'\ I-'
<br />.~...<w I
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<br />,. -;:-.....
<br /> ;;:...n 2 en
<br /> ~""
<br /> :I>- 0 CD
<br />-...-o"""~
<br /> ~ I-'
<br /> '\J\
<br /> r~
<br /> ~,
<br />
<br />02282
<br />
<br />9c INSI5E~6ifYUMiTs
<br />
<br />10. RACE -le.g., While. BlacK. Amerl(;an Indian
<br />etc.1 rSwctfyl
<br />
<br />11. ANCF.STRY Ie 9 l1ahan, Me)(l(;an, German, atcl
<br />ISpe"tyl Irish/Penn Dutch
<br />
<br />Yes~ No D
<br />13 NAME OF SPOUSE Iff wilt! .Qlve maider! name)
<br />
<br />White
<br />
<br />14a USUAL OCCUPA.TION (Give kind of work done during most
<br />
<br />~!itarY7Effigineer
<br />
<br />16 FA TH!::R - NAMf
<br />
<br />MlDDl. F
<br />
<br />LAST 17 MOTHER
<br />
<br />15. EOUCATION (SpeCify only highest grade completed)
<br />EI~fnentary or Secondary (0.' 2) College 11 4 01 ~' I
<br />12 2
<br />MIDDLE MAiDENsuRNA~--- ...
<br />
<br />u.s. Air Force
<br />
<br />F=IRST
<br />
<br />r.1arcus Hoops
<br />'"i8'"WASOEC-EliSEDEV{f"NU'S 'AiiMEO'FORC. ES' -'Jl2.81T942 _"' ~RMANT ~NAMC
<br />Yes ww"'ii;K~~'~>a,v-i~.t~~~3!311I967 Nesle Hoops
<br />19b IN~ORMANT MAILING ADORESS ISTREfT OR R.F 0 NQ CITY OR TOWN. STATE ZIPI
<br />
<br />Nellie
<br />
<br />Smelser
<br />
<br />416 Orleans Drive, Grand Island, Nebraska
<br />
<br />68803
<br />
<br />20. EMBALME;R - SIGNATURE & lICENSE NO
<br />
<br />C tzuj',j L)Lf~ -,_~,'
<br />
<br />21c CEMETERY OR CREMA!OHY NAM!:
<br />
<br />21<1 METHOD OF DISPOSITION
<br />
<br />21b DATE
<br />
<br />-$. (). l 7
<br />
<br />~ Burial D Removal
<br />
<br />02/26/2003 Grand Island City
<br />21d CEMETERY OR CREMATORY LOCATION CITy OR TOWN
<br />
<br />22a. f-l)NE::RAl HOMe:. . NAME;
<br />
<br />Apfel-Butler-Geddes D C'.mallon D D"".Mc
<br />
<br />22b. FUNERAL HOME ADDRESS ISTREET OR A.F,D. NO.. CITY OR TOWN. STATE, ZIP)
<br />
<br />Grand Island, Nebraska
<br />
<br />...... Si:'Al.~
<br />
<br />1123 West Second Street,
<br />
<br />Grand Island, Nebraska 68801
<br />IENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl, AND lell
<br />
<br />23. IMMEODIA Te CAuSE
<br />PART
<br />I
<br />
<br />18 Hours
<br />
<br />Interval between onset aM de,1tr
<br />
<br />Pneunonia
<br />
<br />lal
<br />DUE TO, OR AS A CONSEOUENCE OF
<br />
<br />rn1erval between onset and de"l"
<br />
<br />Ibl
<br />DUe TO, OR AS A CONSEOUeNCf 01"
<br />
<br />lei
<br />I'ART OtHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />
<br />~dynamic Ileus, Parkinson's Disease
<br />
<br />26a.
<br />0 Accident 0
<br />0 Suicide 0
<br />0 ~ion'icldc
<br />
<br />
<br />2Gb. DATE OF INJURY (Mo.. Day. Yr.J 26c HOUR OF INJURY
<br />
<br />Undetermined
<br />
<br />Pending ?6e INJURY AT WORK
<br />InvesI'gallon Yes D No D
<br />
<br />26g. LOCATION
<br />
<br />STRfET OR RF.D. NO.
<br />
<br />CITV OR TOWN
<br />
<br />27a DATE OF DEATH (Mo. Day. Yr.)
<br />
<br />'28.. DATE SIGNED (Mo.. Day. "I
<br />
<br />28b TIME OF DEATH
<br />
<br />iL
<br />!~~
<br />:n~
<br />~o ~
<br />
<br />February 22, 2003
<br />
<br />Zr
<br />i~~
<br />h.,~
<br />~Q........ :;r-
<br />u;Q~g
<br />Jlil6
<br />~H~
<br />
<br />2BE:.. On the baSIS 01 examinallcJn and or inv~51Ig;::JIlon, In my opinion death occurred at
<br />the time. dale and place aM due (0 1M causolsl staled.
<br />
<br />27b. DATe SIGNED (MO., [Joy, y,)
<br />February 24, 2003
<br />
<br />27c TIME OF DEATH
<br />
<br />28e PRONOUNCED DEAD IMo Day., Yr.)
<br />
<br />280. ~RONOUNCED DEAD (HOIJrl
<br />
<br />3:55
<br />
<br />A.
<br />
<br />M
<br />
<br />29
<br />
<br />
<br />G: NO
<br />
<br />he tima, datI;:! i:l.nd place and duo to 1M
<br />
<br />/J!/J
<br />
<br />IS! nature and TitlO) ".
<br />30. HAS ORGAN OR TiSSuE DONATION BEEN CONSIDERED'
<br />
<br />30.tJ WAS CONSE:NT GRANTEO?
<br />DYES
<br />
<br />DYES
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER [P'WSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY 1 (Ty.pe or Print)
<br />
<br />. Steve Higgins,
<br />II
<br />
<br />
<br />Grand Island, NE 68803
<br />32b. DATE FILED Bv HM'tnr IM03ay. 2003
<br />
<br />STAT[
<br />
<br />M
<br />
<br />M
<br />
<br />G NO
<br />
<br />Lot Twenty-seven (ZI), west'"Hngbt:S Mii'tion, Grand Island, Ball County, Nebraska
<br />
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