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r" 2 <br />a <br />n = <br />rrr <br />rn n <br />, <br />\J) l <br />u o --+ <br />Cz <br />CZ) <br />fV <br />C 7 <br />O <br />r- � <br />p <br />�) <br />1; CIO <br />C D <br />�asnaala <br />i T' <br />...,C I 'h <br />!CD �--� <br />1 W Cn <br />-C O <br />- - -LOT 19, BLOCK 2, BEL AIR ADDTION TO THE CITY OF GRAND ISLAND, <br />HALL COUNTY, NEBRAS". <br />/ <br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH•AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE00M QN FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS TI@N. WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />/ : m `S.° <br />6/9/2003 200502944 A$S►$ *ANT�Fh /R <br />HEAL H ANOHHMAN SERVICES S�TfM <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND[J>>dAN S$RVS FI AND SI}PORT <br />_ <br />VITAL STAT7StCS - <br />CERTIFICATE OF DEATH ` Q` <br />11 pEOQWT - NAME FIRST MIDDLE LAST <br />2. SEX <br />DATE OF DEATH (Mandl. Day Year) <br />Sandra Jean E'oi ht <br />Female <br />Ma 31 2003 <br />4. CITY AND STATE OF BIRTH /d not h U.S.A„ Imma cowrdyl <br />50. AGE ^.LVA Birthday <br />UNDER 1 YEAR <br />DAYS <br />UNDER I DAY <br />5C. HOURS MINS. <br />B. DATE OF BIRTH lMOnta- Day. Yddd <br />(Yrs.l 5h <br />MOS, I <br />i <br />Aug 8 1947 <br />Benkelman, Nebraska <br />55 <br />7. $OC1AL SEGURTIY NUMBER <br />as. PLACE OF DEATH <br />HOSPITAL Inpm0W OTHER: ❑ Nursing Home <br />505 -64 -5.719 <br />Rmidence <br />Bb. FACIIJTY - Name (dnMin.�srila'drL B^"s Nreel Brrd maTAW) . <br />F1 Olher (Spetdy) <br />1728 Idlewood Lane <br />ad. INSIDE <br />DOA <br />CITY LIMITS Be. COUNYV OF DEATH <br />ft. . CITY. TOWN OR LOCATION OF DEATH <br />Yea No ❑ <br />Hall <br />Grand Island <br />9C- CITY; TOWN <br />OR LOCATION <br />9d. STREET AND NUMBER (hdudhl9ZlP Cade/ <br />9e. IL111jITY LIMITS <br />Ba. RESIDENCE - STATE <br />9b. COUNTY <br />Grand <br />1728 Idlewood Lane 68803 <br />"° [� <br />Nebraska <br />Hall <br />WNen. 17. ANCESTRY Ie- 9..1aNen. <br />,Island <br />Mexican, German. etcl <br />12. ®MARRIED. ❑ WIDOWED <br />IS. NAMEOF.SPOUSE (d W*..givemaidenda -) <br />1 U. RACE -leg- Whiee. Black. American <br />emllspeclryl <br />(Specify) <br />Scottish <br />NEVER DIVORCED <br />Glen FOl ht <br />ite <br />740_ USUAL OCCUPATION IGAe ldnddEWwk dent dtdf'r9 mob+ 14b. <br />KIND OF 13USINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade CCmpMtad) <br />EJeme or Secondary 10 -12) College l - Cr 5 -1 <br />damp rey�g f_�~ #m*od) <br />1 <br />1 <br />Sr. yscyu+iills tra 1 A <br />LAST 17 <br />MOTHER FIRST <br />MIDDLE MAIDEN SURNAME <br />16. FATHER -NAME FIRST MIDDLE . <br />Ellsworth Wilson <br />Doris Maxwell <br />1!, WAS pECEASED EV�INU FiME6 FORCES? <br />IS& INFORMANT -NAME <br />(Yea. no. br unk.) 1r and does of w-ic"I <br />Glen F4i ht <br />No <br />1 O4 INFORMANT MAILING ADORES3 (STREET OR Fl.F N. .D. N0, CITY OR TOW STATE. ZJP) <br />1728 Idlewood Lane Grand .island <br />NE 68803 21c. CEMETERY OR CREMATORY NAME <br />DATE <br />jj -_ .8 NATURE &.LICENSE.NO - <br />21 a. METHOD OF pISFOSITION <br />❑ Rarnowrl <br />21b, <br />Jun .4 , 2003 <br />Grand Island City <br />09 <br />Q B1,d.1 <br />21d. CEMETERY OR CREMATORY LOCATION <br />CITY OR TOWN STATE <br />2p1ji FUIIERAL HOME -NAME <br />❑D"°'°"°" ❑Dona"°" <br />3168 W. Stolle Park Rd. Grand Island NE <br />CU�:ran Funeral Cha 1 <br />214 FUNERAL HOME ADDRESS ( BTREET OR'FU =.D. NO- CITY OR TOWN. <br />STATE, 21P1 <br />3005 South Locust Street Grand Island NE. 68801 interval between onset and death <br />29. IMMEDIATE CAUSE (ENTER ONE CAUSE PE�q/.•^LMIE FOR lal• 16), AND (CII <br />♦ONLY <br />PART <br />^wry <br />C <br />/Vi t T S�i�jf ` L ` C S / Interval between Onset dntl death <br />a) <br />DUE TO, OR AS A CONSEQUENCE OF: <br />@) I kroerval 3gtvv 1 Onset and death <br />DUE 10, OR AS A CONSEQUENCE OF: <br />I <br />(c) <br />SIGNIFlCANT CONDR'K)N5 - CCndllion5 cOmrlY°dn9 � � death bnt nal relaed pgEGNANCY�THE PPAST 3 MONTHS? <br />I <br />AL <br />24' AUTOPSY 25. EXAMINER OR CORONER: M <br />pA�OTHER <br />II' <br />(Ages 10 -541. Yee No <br />Yea No X Ves No <br />2E6. DATE OF IN.IURY IMa. 1.1aY• Yr./ <br />28c. HOUR OF INJURY <br />28d DESCRIBE HOW INJURY URREp <br />�• <br />Aceklerd ❑ UrWeermined <br />❑ Stdctde ❑ Perdslg <br />M . <br />28o, R"WRY AT WORK 28f. �� la. hee4 htAOry LOCATION 'STREET OR 0.FA. NO. CITY OR YoYfN STATE <br />ElHomicide krvewriabon <br />Yes Nc <br />28s, DATE SIGNED (Ab.. Day, yr) <br />29b. TIME OF DEATH <br />27a. DATE OF DEATH (ft- Day. Yr) <br />1,j f UL✓ <br />DEAD /NCUr1 <br />S <br />`{� <br />g7D. GATE SIGNED /Ab- Day. Yr.) 27c, <br />TIME OF DEATH <br />k <br />Y 2Bc- PRONOUNCED DEAD IM. Day. Y-) <br />25tl. PRONOUNCED <br />� <br />as <br />r <br />Si5g <br />M <br />al <br />;O <br />27d To tie beat d my knowledge. de currad 21 1h 91 daM and and due to the <br />? <br />b <br />206. On the basis d examnason and/or Inesuyadon, m mY opinion death Cccuned <br />the time-doe and pWA and due to IN MUSOS) slakd. <br />L�wtee(sl slllMd 4 <br />sere and 7kle ► <br />_ 5 and <br />m DID TOBACCO USE CONTRIBUTE TO T DEATH? <br />909 HAS gGAN OR TISSUE <br />DONATION BEEN CON6IDEREp? <br />90.b WAS CONSENT GRAN <br />❑ YES <br />❑ YES NO UNKNOWN <br />❑ <br />YES NO <br />N" AND ADDRESS OF CERTVER (PHYSICIAN, CORONER'S PHYSIC NOR (,AUNTY ATTORNEY) /ryps a PMH <br />R ( <br />Dr. David R Colan 719 N. Custer Ave. G d Island NE 68803 Yrj <br />326. DA1E FILER BYJ <br />32s. REGISTRAR. � . <br />U� 6 2003 <br />