200502637 - Laserfiche WebLink

Browse

. MEN MS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALP"MMHUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OHN FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL,, 3`- dDf7k- WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 200502637 �_- EYA COOPER _:ASSISTANT STATE IEE67STRAR LINCOLN, NEBRASKA HEAL 1` ANb_HUMAN.S,ERVICE & BYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND MAIM 59 i61ANWAND SUPPORT vrrALSTATISTICS' -..'- CERTIFICATE OF DEAIEL I. DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH !Month. Day. Year) Ralph Francis Doud Male I September 8, 1998 4. CITY AND STATE OF BIRTH tflnot in USA„ name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRTH /Mdndt. Day. Year) EXAMINER OR CORONER' (Yrs.l (Ages 10 -541 Yes NO 5b. MOS. DAYS 5c. HOURS' MINS. Cascade, Iowa 84 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED June 4, 1914 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 482 -10 -2299 HOSPITAL: ❑ Inpalient OTHER ❑ Nursing Home 8b. FACILITY - Name tffnorinsetueort. give strawandnumber) ER Outpatient Q Residence 1717 N. Wheeler Avenue ❑ DOA ❑ Otherf$pacdvi 8c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ❑X No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code) 68pO00 ol ge. INSIDE CITY LIMITS Nebraska Hall Grand Island 1717 N. Wheeler Ave. Yes [A No ❑ 10. RACE • (a g., White. Black, American Indian 11, ANCESTRY Ie.g.. fallen, Mexican, German, etc) L 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE of wiM. give maiden name) etc.) (SPecey) White ISpecilyl I American NEVER DIVORCED Mar aret Hastert 14a. USUAL OCCUPATION /Give kind of work done dunng moss Y�) V 14b� KIND OF BUSINESS INDUSTRY ( -7 1 / t ( 15. EDUCATION (Spaciy only highest grade completed) Elementalorr ondary (0 -12) Collage 11 -4 or 5•I of working life, even it mrired/ M Co-Advertising Manager News r 2 16. FATHER • NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Jacob L. Doud Kathr n Orban 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.l (If yes. give war and datas M services) ) No M Doud 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN, STATE. ZIPI 1717 N. Wheeler Ave. Grand Island Nebraska 68801 20. EM R • CENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME 7TU /Z/Z ® Burial ❑ Removal e t . 11 1998 Westlawn Mem. Park Cemeter 22a. FUNERAL ME NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE TH? ❑ Cliental' ❑ 30.b WAS CONSENT GRANTED? A fel- Butler- Geddes F.H. UNKNOWN Grand Island Nebraska 22b, FUNERAL HOME ADDRESS (STREET OR RF.D. NO., CITY OR TOWN, STATE, ZIP) 1123 W. Second Street Grand Island Nebraska 68801 23. IMMEDIATE CAUSE (L"N1LH ONLY UNL (;AUSL PLH LINL I-VH Ia). 1D), ANU ICII imervin co een onset anp aea�� PART (al i IM DUE TO, OR AS A CONS11GUENCE OF r, Interval bemoan onset and dealn Ibl DUE C-< between onset and death (c) I OTHER SIGNIFICANT CONDITIONS - Cond4ion; contributing to me death but not related PART III IF FEMALE WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER' II (Ages 10 -541 Yes NO Yes D No Ves No 26a. 26b. DATE OF INJURY tMo.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ❑ Accident ❑ Undetermmad M ❑ Suicide ❑ Pending 26e. INJURY AT WORK 2:g RFJNJURY - t hop, farm. sneer. factory ding 26g. LOCATION STREET OR R.F,O. NO. CITY OR TOWN .STATE Homicide Investigation ❑❑ yes No ❑ III etc 27a. DATE OF DEATH /ono.. Day. Yr) 28a. DATE SIGNED (Mo.. Oav Yr) 28b TIME OF DEATH - September 8, 1998 t • „z �Yi M 27b. DATE SIGNED /ono.. Day. Yr1 27c. TIME OF DEATH 26c PRONOUNCED DEAD (Mo. Day. Yr.) 28d. PRONOUNCED DEAD /Hours I a J I k September 8,1998 :15 AM M .2 27d. T° the bast W knowledg atn occurred al ttIe ima, to and pl a and due td the 28e. On the basis of examination And,or Investigation, in my opinion death occurred at causelsl stated. n the time, date and place and due to the cause stated. f ISI nature and Title (Signature and Titlel Do 29. DID TOBACCO USE CONTRI TE TO THE TH? 30.a AS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? 1-1 YES FNO UNKNOWN 1:1 12, 12, ❑ YES �NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type n-PnntJ Dr. Ran Crouch, DO 800 ha Gran I land Nebraska 68803 32a. REGISTRAR 32b. DATE FILED BY Fism V` 1111 ©© IF