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WHEN THIS COPY CA RAISED SEAL OF THE NEBRASKA HEALTH AMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC DON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC"EMON; -WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AztNLEYS. COOPED
<br />6/23/2003 200502077 AS &IVIANT=AT-FE3-GIST-R -AR.
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN- SERft*i 1Y6TEI
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEIRVI fS FDfM T AND�SUI!PORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH (1 "= _ � J 06962
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IMpnm. Day. Year)
<br />Helen E. G'erloff
<br />Female
<br />June 14 2003
<br />4. CITY AND STATE OF BIRTH of not in U.S.A. name country)
<br />5a. AGE • Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAV
<br />6. DATE OF BIRTH /Month, Day Year)
<br />5b. MOS. DAYS
<br />5c. HOURS MINS.
<br />EXAMINER OR CORONER'
<br />(Yrs.)
<br />York, Nebraska
<br />87
<br />Yes r No
<br />26a.
<br />January 28 1916
<br />J 7, SOCIAL SECURTIY NUMBER
<br />8a, PLACE OF DEATH
<br />.1 505 -58 -1062
<br />HOSPITAL : Inpatient OTHER_: ® Nursing Home
<br />ER Outpatient Residence
<br />j8b. FACILITY - Name i1friot institution, give street and number)
<br />Tiffany Square
<br />DOA Other tSpecwtvi
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMSER /Including �p Codel
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2209 N: Rue de Colle e
<br />Yea ® No ❑
<br />10. RACE - (e,g., White. Black. American Indian.
<br />11. ANCESTRY fe g., Italian, Mexican, German, etc)
<br />12. © MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (ff wde. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />R
<br />Christian G"erloff
<br />- 14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary br Secondary (0 -12) 1 2 College (1 -4 or 5.1
<br />of working life, even it rettred)
<br />Secretary
<br />_
<br />Church
<br />r, 16, FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harry Cain
<br />Laverne Coleman
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT • NAME
<br />- (ves. no, or unk,) (a yes. give war and dates of services)
<br />28d, PRONOUNCED DEAD (Hour)
<br />N I
<br />Christian G"erloff
<br />19b, INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2209 North Rue de College, Grand Island Nebraska 68803
<br />20. EMBALMER - SIGNATURE S LICENSE NO.
<br />21 a. METHOD Or DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑ Burial ❑ Removal
<br />06 -14 -2003
<br />Central NE Cremation Servi
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes Funeral HOmtliw
<br />Cremation ❑Donanon
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />1123 West Second St. Grand Island, Nebraska 68801
<br />1 23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PInH UNt I-UH lal, (bl, AND (c)) Imerval between onset anp seam
<br />PART ��/ p,� � f I
<br />I (al CCi/�% G t1 -r %Cit? /f �177��� /i�� -�C ; /V�-
<br />II DUE TO, OR AS A CONSEQUENCE 05 Interval between onset and death
<br />* I
<br />ce
<br />DUE TO, OR AS A CONSEQUENCE OF'
<br />I Interval between onset and death
<br />I
<br />(c)
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />I
<br />(Ages 10 -541 Yes No
<br />Yes No
<br />Yes r No
<br />26a.
<br />26b. DATE OF INJURY tMa.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />'
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f, PACE C;F INJURY At home.
<br />ding,
<br />farm, Ftrset. factory
<br />26g. LOCATION STREET OR R.P.D. NO. .CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑. No ❑
<br />o ce ul etc. / pecrry/
<br />27a. DATE OF DEATH (Moo Day, Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME of DEATH
<br />'�•T
<br />'r /
<br />S 3
<br />lY / /
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />2BC. PRONOUNCED DEAD (Mo.. Day, Yc)
<br />28d, PRONOUNCED DEAD (Hour)
<br />8:37 a.
<br />M
<br />�
<br />M
<br />$.
<br />27d. To the best of my kno , death occuy(e4at the tlm , calo and place and due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />I e
<br />9 °
<br />I.
<br />Causelsl staled.
<br />°
<br />the time, date and place and due to the causels) Stated.
<br />i
<br />(Signature and Title! Pop
<br />ISi nature and Title)
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />WAS CONSENT GRANTED?
<br />1:1 YES NO UNKNOWN
<br />❑ YES NO
<br />❑ YES N7 NO
<br />31. NAME AND ADDRESS OF dERTIFIEF (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or l-nng
<br />David Colan M.D. 729 N. Cust r,
<br />Grand Island, NE 68803
<br />328, REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />.40k
<br />L �Pm
<br />JUN 2 0
<br />
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