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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ,ON FILE W,,/TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC_T101% -OVICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE.
<br />200502363 t ANLEY s. COOPER
<br />9/28/2004 ASS /S] ANT44TAAEGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES`SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES Fit M4CE ANI2 SbPPORT
<br />VITAL STATISTICS -_ 4 5
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Yearl
<br />Edna A, Mead
<br />Female
<br />September 18, 2004
<br />4. CITY AND STATE OF BIRTH i f notin U.S.A.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH /Month. Day, Year/
<br />Grand Tsland, Nebraska
<br />(Vrs.l
<br />92
<br />54. MOS. DAYS
<br />5c. HOURS' MINS.
<br />February 22, 1912
<br />7. SOCIAL SECUR71Y NUMBER
<br />Be. PLACE OF DEATH
<br />507 -38 -6984
<br />HOSPITAL: ❑ Inpatient OTHER_: ® Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name (If not institution, give Street and numberl
<br />Beverly Heathcare Park Place
<br />❑ DOA ❑ OtherrsPecttw
<br />Be. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Grand Island Yes ® No ❑ Hall
<br />9a. RFSioENCE - STATE 9b. COUNTY _ 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (lnduoing Zip Cade) 9e. INSIDE CITY LIMITS
<br />Nebraska Hall Wood River 103 East 5th St. 68883 Yes &] No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc)
<br />12. ❑ MARRIED ® WIDOWED
<br />13, NAME DOFF SPOUSE /1f wile. give maiden name)
<br />etc.l(SpeGlja{I lte
<br />W Y1
<br />(Specify) American
<br />NEVER OIVORCED
<br />MARR
<br />Delbert Mead (dec)
<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 />Ele ntary or Secondary 10 -12) College H -4 or 5.1
<br />of working life, even if refired!
<br />Homemaker
<br />Domestic
<br />16, FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto Wiese
<br />Elvzna UNKNOWN
<br />18. WAS DECEASED EVER IN U.S, ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes, no, or unit.) (if yes. give war and dates of services)
<br />� No
<br />Darrell Mead
<br />19b. INIFUHMANI MAILING AUUHtbb (b I Mint VM M.r. U. NU.. VII r UM I ij-,,S I Ir ur•)
<br />470 Hwy 11, Dannebrog, NE 68831
<br />20, EM 8 fAE - SIGNATURE 8 LI NSE N 1Z V `) 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />LJ Q Burial ❑ Removal Sept. 22, 200 Wood River Cemetery
<br />22a, FUNERAL HOME - NAME
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />PART PREGNANCY
<br />�\
<br />❑cremation
<br />[] Donation
<br />Wood River, NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />411 West 11th St.
<br />P.O. Box 126,
<br />Wood
<br />River, NE 68883
<br />23. IMMEDIATE CAUSE
<br />(ENTER ONLY ONE CAUSE PE LINE FOR fal. (b). AND (c)) I Interval between onset and death
<br />q� \
<br />PART r'
<br />d.J ., � a. \j s�
<br />� W \ �
<br />�. �
<br />L � �q
<br />iCn
<br />u •
<br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />DUE TO, OR AS ONSEQUENCE OF
<br />Interval between onset and death
<br />(b)
<br />28a. DATE SIGNED /Mo.. Day. Yrl
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF! Interval between onset and death
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />�\
<br />IN THE PAST 3 MONT S?
<br />EXAMINER OR CORONE .?
<br />II
<br />r
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />28b. DATE OF INJURY (Ma. Day. Yc1
<br />28c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OtC RRED
<br />7 Accident F-1 Undetermined
<br />M
<br />FI Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />28f, o81ce CE 9F INJURY 4th p. farm. street. factory
<br />LLqq � qq
<br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /Mo.. Day. YrJ
<br />28a. DATE SIGNED /Mo.. Day. Yrl
<br />284. TIME OF DEATH
<br />September 18, 2004
<br />a
<br />M
<br />27b. DATE SIGNED (Mo Day. Yr.)
<br />27c, TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />a }
<br />�o
<br />9i I- ��
<br />3t'�l� �M
<br />��o
<br />$
<br />,
<br />M
<br />27d. To the neat of my knowledge. death at the time, date and place and due to the
<br />occurr
<br />2Be. On the basis of examination and,or investigation, in my opinion death occurred at
<br />1
<br />2 g cg
<br />cause's) stated. (�
<br />\A`
<br />6 b
<br />the time, date and place and due to the eause(sl stated.
<br />•t!V)
<br />I (Signature and Title) ►
<br />(Signature and Title
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION �,B`EEEE�Nl CONSIDERED?
<br />30 -b WAS CONSENT GRANTED?
<br />❑ YES ` NO ❑ UNKNOWN
<br />(
<br />❑ YES 1 XI NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type w Rnni))
<br />D.C. Wirth M.D. 2116 W. F idley Ave., Suite 400, Grand Island, NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />SEP 2 7 2004
<br />
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