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STATE OF NEBRASKA
<br />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 WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE_ C-TION; 1i0H_4S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -~
<br />MAR 2 5 2005 TAIVLEYS. COOPER
<br />ASSISTAI s- .Ta7E.R GISTRAR'
<br />LINCOLN, NEBRASKA HEALTH AWHUMAN SERVICEg
<br />200502722
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT -=
<br />CERTIFICATE OF DEATH 88
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3.DATEOFDEATH(Mo.,Day,Yr.)
<br />Edna B. W. Hines Female March 18, 2005
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yf.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />Grand Island, Nebraska 76 July 9, 1928
<br />7, SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />-507-30-9671 _ _
<br />Hi MFJT&L: N Inpatient .OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY-NAME (If not Inst4utlon, glVe street and number)
<br />IMMEOIATECAUrW 1
<br />1 onsettodeaathr\
<br />., _.❑ EFl,'Outpallent ❑ Decedent's Home
<br />St. Francis Medical Center
<br />_ 1
<br />I ousel t0 death
<br />❑ DQA Cl Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />ed. COUNTY OF DEATH
<br />Grand Island . -.�_�- 8803
<br />Hall
<br />9a. RESIDENCE•STATE 9b. COUNTY
<br />9c, CITY OR TOWN
<br />Nebraska Ha11
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1304 N Geddes
<br />9e. APT NO 9f ZIP CODE 9g, INSIDE CITY LIMITS
<br />68801 M YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH {Married U Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />*10111(fti, but separated LJ Widowed ❑ Divorced ❑ Unknown Robert
<br />E. Hines, Sr.
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Richard (NMI) Poehler
<br />Ida (NMI) Kruse
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service II yes. 149. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, or unk.) No Robert E.
<br />15. METHOD OF DISPOSITION 16e. Efvj ALME!R -S TUR
<br />Hines, Sr. Husband
<br />16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br />X) Burial L] Donation "'i
<br />II x` March 22, 2005
<br />Cl Cremation U Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY l TOWN STATE
<br />❑Removal 0 Other (Specify) Grand Island City
<br />Cemetery, Grand. Island, Nebraska
<br />--
<br />Y
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (St3213rTO�,SNOrth
<br />17b. ZIP Code
<br />Kleine Funeral Home,
<br />Front St. Grand h sland,NE 68803
<br />18. PART I. Enter trio chain of events-- diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular flbrlllallon without showing the etiology. DO NOT ABBREVIATE. Enteronly one cause on a line. Add additional lines If n
<br />necessary. I
<br />IMMEOIATECAUrW 1
<br />1 onsettodeaathr\
<br />IMMEDIATE CAUSE (Final _ (a) c�Y : C 1 _
<br />IyNa r_
<br />_ 1
<br />I ousel t0 death
<br />in death) t„ 1
<br />a
<br />�..
<br />_ 1
<br />Sequentially
<br />adIng of c
<br />I
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />Cl YES �,iJtl
<br />221. LOCATION OF INJURY • STREET & NUMBER, APT, NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.) r
<br />� W
<br />Q to z
<br />v _ch .. �. - V Fn 0
<br />y 23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH'
<br />Y
<br />omo M..c 1$ 2005 9 m Eyaz
<br />23d. To the best of my knowledge, death occurred at the time, date and place w x
<br />A uses) s �. (Signature nd Title) ♦ .� o p
<br />c m o
<br />-:;z . r :rf4 �2(�i)I , U a
<br />25. DD TOBACCO USE CON4RIBUTE TO THE DEATH?
<br />❑ YES cA NO U PROBABLY Cl UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, C
<br />Dr. Ryan D Crouch DO
<br />288, REGISTRAR'S SIGNATURE w
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo,, Day, Yr.)
<br />ZIP CODE
<br />24b.TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and /or investlgatlon, In my opinion death occurred at
<br />the time, Gate and place and due to the cause(s) stated. (Signature and Title )
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES .0 NO Not Applicable It 26a Is NO ❑ YES NO
<br />VER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />800 Alpha Grand Ts'and,NE 681103
<br />28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr,)
<br />MAR 2 3 2005
<br />25. DD TOBACCO USE CON4RIBUTE TO THE DEATH?
<br />❑ YES cA NO U PROBABLY Cl UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, C
<br />Dr. Ryan D Crouch DO
<br />288, REGISTRAR'S SIGNATURE w
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo,, Day, Yr.)
<br />ZIP CODE
<br />24b.TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and /or investlgatlon, In my opinion death occurred at
<br />the time, Gate and place and due to the cause(s) stated. (Signature and Title )
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES .0 NO Not Applicable It 26a Is NO ❑ YES NO
<br />VER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />800 Alpha Grand Ts'and,NE 681103
<br />28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr,)
<br />MAR 2 3 2005
<br />
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