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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS 00 THE LEGAL DEPOSITORY FOR VITAL RECORDS. / rJ -_g, DATE OF ISSUANCE )Ot ANN /L/EY S. 'CCOOPER q�„q�/ 2005029410 STATE REGISTRAR MAY �` 19 �� ASSISTANT LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF MALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1 ❑LCEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DAl E OF DEATH lMnnrh Dal, Year) Joyce Pichler Female April 12, 1999 4. CITY AND STATE OF BIRTH (fl nofn U.SA. name country/ 5a AGE � Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH IMOOA7. Gay Year) (Y'5) 59 5b MOS DAYS Sc.MDURS' MINS JaIlllary 17, 1940 Greeley, Nebraska -� Ba. PLACE OF DEATH 7 SOCIAL $ECURTIY NUMBER HOSPITAL � Inpatient OTHER Nursing Home 506 -60 -6742 ER outpatient Residence 8h FACILITY - Namo (If not msf/Iufian, give 5/r@ef and number) ❑ ❑ - DOA Other (Speodvl Bryan /LGH Fast Bid INSIDE CITY LIMITS Be COUNTY OF DEATH Be CITY TOWN OR LOCATION OF DEATH ❑ Yes X ❑ NO Lancaster _ Lincoln 9a. RESIDENCE -STATE 9h. COUNTY 9c. CITV, TOwN OR LOCATION 9d. STREET AND NUMBER (Including lip Code) 9e INSIDE CITY LIMITS Grand Island 2211 W. 11th St. 68803 Yes X] No Nebraska Hall M - ® ARRIED 1-1 WIDOWED 13. NAME OF SPOUSE M wife give maiden namel 10. RACE - (e.g.. While. Black. American Indian. 12. 11. ANCESTRY le.g.. Italian. McKlcan, German, etc) Y ISpeclly) American L NEVER DIVORCED Larry L. Pichler MA 1 15. EDUCATION ISpecdy only hlgnesl grade cpmplUled) 146 KIND OF BUSINESS INDUSTRY Cove I1 .a 0, 5•I 14. . USUALOCCUPATION IGrvekmdofworkdone during most Elemenle(yor Secondary 10 -121 9¢ Yoof working li /e. eyery} /I rehredl Domestic II .�.� 1 oM'e`fWT'le FIRST MIDDLE MAIDEN SURNAME 16 FATHER- NAME FIRST MIDDLE t7 MOTHER F3engel Mae McVay Heber 19a INFORMANT •NAME 18 WAS DECEASED EVER IN U.S. ARMED FORCES? . I c of unk'1 71 yes g've war and dales of services) T a rr- y L. Pichler -.. 0�� 1TOWN STATE t9b INFORMANT MAILING ADDRESS [STREET OR R.F.D Np.. CITV DR TOWN STATE ZIP' 2211 West 11th Street Grand Island? Nebraska 68803 21 a METHOD OF DISPOSITION 216 DATE - 21G CEMETERY DR CREMATORY NAME 20 EMBALMER • 51 ATURE 8 LICENSE NO. . . ®Burls) ❑ Removal April 16, 1999 Grand Island City Cemetery 21n CEMETERY OR CREMATORY LOCATION CITY OH TOWN STATE 1 'FUNER�,,,A.E J r I 7 T� 7 r F.H. ❑ Crernww ❑ Donation Grand. Island, Nebraska 226 rF fe HOME Alder -`�de� RrF'.D. NO. CITY OR TOWN. STATE. ZIPI - 1123 West 2nd Street Grand Island, Nebraska 68801 -5899 nlerval F¢� een rinse) and null, 23. IMMEDIATE CAUSE IENTERI ONLY ONE CAUSE PER LINE FOR lal. Ib). AND jell I PART � 1 � S I Y G` � V Y' +t I Imewal ttPtwaen onset and nealn Ial DUE TO p ASA CO SEQUENCE OF 161 R` / r r �• I r f L I F' / "' -S ��'•' Interval between onset arid 0,, I DUE 10. OR AS A CONSEQUENCE OF I _ P N e. v car h r s e ICI PART II IF FEMALE. WAS �3MONTHS�? E A 24 AUTOPSY 25. WAS -CASE REFERRED f0 MEDICAL T OTHER SIGNIFICANT CONDITIONS - Conditions Conlfibutiny 101h¢ death but not related E %n MINER OR CORONER' PREGNANCY IN l HE PASPART Yes N0 J S L l / L r (Ages 10 54) Yes No ------ ��••'' °A° °°°�� - Ves..J�L. No 26a. 266. DATE OF INJURY Imo.. Day. Yr.1 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ACGdent llndete -ned M - 1 Suicide Pendlnq 26e. INJURY AT WORK 261 oldicA j QdtnNJe INJURY -At horyl Ierm. street factory 2G9. LOCATION SY FEET OH R F O NO GIl Y OR l OWN SI A 7F - Hnm,clde Investigation Yes F-1 No 286. TIME OF DEATN 28a DATE SIGNED IMO.. Day Yr.l 27a DATE OF DEATH IMo.. Day. "I ,�_) � aw M E 27c TIME OF DEATH y r k 28c PRONOUNCED DEAD /Mo.. Day. Yr.l 28d. PRONOUNCED DEAD lHnu.l �uui 276 GATE SIGNED 1'��Ynl� M "I M goa R to and ce a �IO t e S o 28e. On the basis of examination due mve ause n, 'm my Ppinipn death occurred al 27n. To ilia bBSt 01 my knowledge. d ecurrad at the lime, � the Ume, dale and place and due 10 the [ausej5) stated . r c, L2JS¢I51 StAled. I ISI nature and Title [Si nature and T4I¢I ► 3D.a HAS OR OR TISSUE DONATION BEEN CONSIDERED'+ 30 1, WAS CONSENT GRANTED' �y�-f/I 29. DID TOBACCO USE CONTRIBUTE T HE DEATH? YES K-��! NO ❑I /"yam UNKNOWN � YES NO _ YES � NO 31, NAME AND ADDRESS OF CERTIFIER IPHYSIGIAN, CORONER 'S PHYSICLAN OR Cl!OUNTY A�CTTaaORNEY' )/IType or PnnIJ �- ��eV-� I v 32b DATE FILED BY REGISTRAR /Mo Day Yrl 32a HEFI$THAR APR 2 61999