|
u
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN _
<br />SERD�`E
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECDRaON F10E*ITIf
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS Sp4i l6- jw�lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. r
<br />DATE OF ISSUANCE (f,J
<br />1AAR 62003 200502884
<br />ASSISTANT- 4TATE REGIST
<br />LINCOLN, NEBRASKA HEALTH AND HUM Q►_ AE*6CE"y4`W; YL
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIiii _ T '.
<br />VITAL STATISTICS
<br />CF.RTTFICATF. OF nFATW n� n 7 9 P7
<br />1 DECEDENT -NAME• FIRS! MIDDLE LAST
<br />2. SEX
<br />3. DAZOE EATH / Month Pay Yea)
<br />Eugene Herschel Hoops
<br />;00
<br />n
<br />1 4, CITY AND STATE OF BIRTH 0not In U S.A.. name Country!
<br />5a. AGE • Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH /Mari Day. Year)
<br />t ..tom
<br />5C.HOURS' MINS
<br />Springview, Nebraska
<br />Y's .l 83
<br />M
<br />C
<br />_
<br />M to `
<br />T�
<br />8a. PLACE OF DEATH
<br />505 -16 -5520
<br />HOSPITAL ❑ Inpatient OTHER_ Nursing Home
<br />c> (n
<br />C�
<br />8b FACILITY - Name /d not institution, give streer and number)
<br />Grand Island Veterans Hane
<br />-
<br />ii
<br />8c CITY, TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Yila_j -trq. ❑
<br />- _...f-���;•y...,..- ......,,, , . ..:. .: _.. ,. .. .... .,....
<br />9a. RESIDENCE • STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncruding Zip Code!
<br />9c INSIDE CITY LIMITS
<br />>
<br />t �"!
<br />Grand Island 1416
<br />Orleans Dr., 68803
<br />��_
<br />f' 1
<br />C=)
<br />,-! No ❑
<br />M
<br />11. ANCESTRY le. g. Italian. Mexican. German, etc
<br />12. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /II wde. .give maiden name/
<br />etc.) (Specify) White
<br />Mite
<br />(Spec - "' Irish /Penn Dutch
<br />NEVER DIVORCED
<br />MARRI
<br />C)
<br />(�
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Speeity, only highest grade completed(
<br />Wo rhg ll"te,�e�ve�n r7r 1
<br />1Ldry ngineer
<br />U.S. Air Force
<br />_ - -••
<br />Elementary or,SQCondary 10 -121 College I I^ 0, 5 • I
<br />11 2
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Marcus Hoops
<br />Nellie Smelser
<br />18 WAS DECEASED EVER IN US. ARMED FORCES? 28 1 2-
<br />19a INFORMANT - NAME
<br />(Yes. 0.^'•• ^1' 1 Iff-we - - -a ......... ,r .,,...
<br />Yesy�,I TI; Korea, Vietnam /31/1 7
<br />Nesle Hoops
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP(
<br />416 Orleans Drive, Grand Tsland, Nebraska 68803
<br />20. EMBALMER - SIGNATURE 6 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />216 DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />Ul m
<br />Removal
<br />02/26/2003
<br />Grand Island City
<br />22a. FUNERAL HOME- NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑Derision
<br />Grand Island, Nebraska
<br />rT1
<br />1123 West Second Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tal. Ib(. AND (c) Interval between onset and deaw
<br />PART
<br />(al Pneumonia 18 Hours
<br />DUE T0, OR AS A CONSEQUENCE OF Interval between onset and deals,
<br />t
<br />•,
<br />rbl t
<br />DUE TO, OR AS A CONSEOUENCE OF ....._._... "� � Interval between onset and deSY
<br />I
<br />(cl I
<br />L
<br />III IF FEMALE. WAS THERE A 74
<br />Tr CTS
<br />c::)
<br />N
<br />IN THE PAST 3 MONTHS?
<br />7
<br />EXAMINER OR CORONER"
<br />(Ages
<br />10.54( Yes No
<br />n
<br />Yes No
<br />3
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />Co
<br />Accident ❑ Undetermined
<br />M
<br />F1 Suicide [] Pending
<br />26e. INJVRY AT WORK
<br />261 PLACE OF INJURY - At hpmg, term. street. Iadipry
<br />o iCe building, etc (Specify/
<br />76g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN _ STATE
<br />Homicide Investigation
<br />Ves No
<br />❑ 1:1
<br />27a. DATE OF DEATH /Mo. Day. Yr.J
<br />28a DATE SIGNED /Mp.. Day. Yr.l
<br />28b. TIME OF'DEAI H
<br />r =
<br />C�3
<br />Co
<br />M
<br />s`
<br />27b. DATE SIGNED (Md.. Day. Y,)
<br />27C TIME OF DEATH
<br />26c. PRONOUNCED DEAD (Mo.. Oay, Yr.)
<br />-
<br />2W. PRONOUNCED DEAD (Hour,,
<br />W
<br />Fs
<br />February 24, 2003
<br />3:55 A. M
<br />�
<br />M
<br />21
<br />°
<br />27d. To the best 01 my knowledge at rurred a ha limo. tlale and olare and due to the
<br />28e. On the basis of examination and or investigation, in my opinion dealt, occurred at v
<br />(_n
<br />Cause(s) stated.
<br />�,
<br />the time. date and dace and due to the cause(sl stated.
<br />(Signature and Title) "�
<br />(Si nature and Tit
<br />29. DID TOBACCO USE CONTRIBU TO THE DEA ? 30
<br />a HAS ORGAN OR I ISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRAN-rEp°
<br />❑ YES ® NO ❑. UNKNOWN
<br />.G7
<br />❑ YES NO
<br />u
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN _
<br />SERD�`E
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECDRaON F10E*ITIf
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS Sp4i l6- jw�lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. r
<br />DATE OF ISSUANCE (f,J
<br />1AAR 62003 200502884
<br />ASSISTANT- 4TATE REGIST
<br />LINCOLN, NEBRASKA HEALTH AND HUM Q►_ AE*6CE"y4`W; YL
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIiii _ T '.
<br />VITAL STATISTICS
<br />CF.RTTFICATF. OF nFATW n� n 7 9 P7
<br />1 DECEDENT -NAME• FIRS! MIDDLE LAST
<br />2. SEX
<br />3. DAZOE EATH / Month Pay Yea)
<br />Eugene Herschel Hoops
<br />Male
<br />Fuary 22, 2003
<br />1 4, CITY AND STATE OF BIRTH 0not In U S.A.. name Country!
<br />5a. AGE • Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH /Mari Day. Year)
<br />=
<br />5C.HOURS' MINS
<br />Springview, Nebraska
<br />Y's .l 83
<br />C3LUJC
<br />November 1, 1919
<br />7. SOCIAL SECURTIY NUMBER
<br />T�
<br />8a. PLACE OF DEATH
<br />505 -16 -5520
<br />HOSPITAL ❑ Inpatient OTHER_ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name /d not institution, give streer and number)
<br />Grand Island Veterans Hane
<br />-
<br />❑ DOA ❑ Other (SpecAVr
<br />8c CITY, TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Yila_j -trq. ❑
<br />- _...f-���;•y...,..- ......,,, , . ..:. .: _.. ,. .. .... .,....
<br />9a. RESIDENCE • STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncruding Zip Code!
<br />9c INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island 1416
<br />Orleans Dr., 68803
<br />,-! No ❑
<br />10 RACE - (e.g., White. Black, American Indian,
<br />11. ANCESTRY le. g. Italian. Mexican. German, etc
<br />12. MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /II wde. .give maiden name/
<br />etc.) (Specify) White
<br />Mite
<br />(Spec - "' Irish /Penn Dutch
<br />NEVER DIVORCED
<br />MARRI
<br />Nesle Kenar
<br />148. USUAL OCCUPATION /Give kind of work done during most 14b
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Speeity, only highest grade completed(
<br />Wo rhg ll"te,�e�ve�n r7r 1
<br />1Ldry ngineer
<br />U.S. Air Force
<br />_ - -••
<br />Elementary or,SQCondary 10 -121 College I I^ 0, 5 • I
<br />11 2
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Marcus Hoops
<br />Nellie Smelser
<br />18 WAS DECEASED EVER IN US. ARMED FORCES? 28 1 2-
<br />19a INFORMANT - NAME
<br />(Yes. 0.^'•• ^1' 1 Iff-we - - -a ......... ,r .,,...
<br />Yesy�,I TI; Korea, Vietnam /31/1 7
<br />Nesle Hoops
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP(
<br />416 Orleans Drive, Grand Tsland, Nebraska 68803
<br />20. EMBALMER - SIGNATURE 6 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />216 DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />LJ12z7
<br />Removal
<br />02/26/2003
<br />Grand Island City
<br />22a. FUNERAL HOME- NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Cremation ❑Derision
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP(
<br />1123 West Second Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR tal. Ib(. AND (c) Interval between onset and deaw
<br />PART
<br />(al Pneumonia 18 Hours
<br />DUE T0, OR AS A CONSEQUENCE OF Interval between onset and deals,
<br />t
<br />•,
<br />rbl t
<br />DUE TO, OR AS A CONSEOUENCE OF ....._._... "� � Interval between onset and deSY
<br />I
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 74
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />Edynalnic Ileus, Parkinson's Disease
<br />IN THE PAST 3 MONTHS?
<br />7
<br />EXAMINER OR CORONER"
<br />(Ages
<br />10.54( Yes No
<br />Yes No
<br />Yes No
<br />260.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined
<br />M
<br />F1 Suicide [] Pending
<br />26e. INJVRY AT WORK
<br />261 PLACE OF INJURY - At hpmg, term. street. Iadipry
<br />o iCe building, etc (Specify/
<br />76g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN _ STATE
<br />Homicide Investigation
<br />Ves No
<br />❑ 1:1
<br />27a. DATE OF DEATH /Mo. Day. Yr.J
<br />28a DATE SIGNED /Mp.. Day. Yr.l
<br />28b. TIME OF'DEAI H
<br />r =
<br />February 22, 2003
<br />M
<br />s`
<br />27b. DATE SIGNED (Md.. Day. Y,)
<br />27C TIME OF DEATH
<br />26c. PRONOUNCED DEAD (Mo.. Oay, Yr.)
<br />-
<br />2W. PRONOUNCED DEAD (Hour,,
<br />a
<br />Fs
<br />February 24, 2003
<br />3:55 A. M
<br />�
<br />M
<br />21
<br />°
<br />27d. To the best 01 my knowledge at rurred a ha limo. tlale and olare and due to the
<br />28e. On the basis of examination and or investigation, in my opinion dealt, occurred at v
<br />1
<br />Cause(s) stated.
<br />�,
<br />the time. date and dace and due to the cause(sl stated.
<br />(Signature and Title) "�
<br />(Si nature and Tit
<br />29. DID TOBACCO USE CONTRIBU TO THE DEA ? 30
<br />a HAS ORGAN OR I ISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRAN-rEp°
<br />❑ YES ® NO ❑. UNKNOWN
<br />❑ YES [a NO
<br />❑ YES NO
<br />3t. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print)
<br />Steve Higgins, M.D., sland Veter s Home, Grand Island, NE 68803
<br />32a. REGISTRAR
<br />!7A
<br />32b DATE FILED 8Y REGISTRAR /Mo.. Day. Yr./o03 AR 3
<br />u
<br />LEGAL: LOT THTRTEEX (131 KALLCT §UBDIVISIONI, IN THE UITT OTMAND ISLANDf
<br />HALL COUNTY, NEBRASKA
<br />k'
<br />
|