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WHEN THIS C&YCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD. ON 'er` WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SW1QilQ*yl C jS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Ar
<br />DATE OF ISSUANCE u N
<br />ANLEY COOPER
<br />9/29/2003 2 0 0 5 0 3 0 0 7 ASSISTANT STATC R GIStRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAI:SERVICES Si *Af
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FJNA_ NCE AND I� 10676
<br />VITAL STATISTICS `J�
<br />CERTIFICATE OF DEATH
<br />FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH tMonlhpay Year]
<br />Caroline NMN Lockwood
<br />=BIRTH
<br />Female
<br />Se tember 18 2003
<br />phut in U.S.A., name country]
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAV
<br />1 6. DATE OF BIRTH /Month. Day. Year/
<br />Yes L No,..
<br />(Yrs.)
<br />50. MO$. I DAYS
<br />5c, HOURS' MIN$.
<br />22a. FUNERAL E - NAME
<br />Beatrice Nebraska
<br />1
<br />1
<br />June 13 1912
<br />■ 7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER Nursing Home
<br />506-58-9883
<br />- - --
<br />El ER Outpatient ❑ Residence
<br />8b. FACILITY - Name ilf not institution, give street and number)
<br />Lakeview Nursin /Rehab Center
<br />DOA Other iSpecdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />Grand Island.
<br />Hall .... ..
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncluding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1405 W. Hi hwa 3468801
<br />Yes N❑ No ❑
<br />10. RACE • (e.g., White. Black. American Indian.
<br />11. ANCESTRY leg.. Italian. Mexican, German, etcl 12. ❑ MARRIED WIDOWED
<br />13. NAME OF SPOUSE Irf wile. give maiden name)
<br />etc.) ISpeciry)
<br />White
<br />(Speclryl NEVER DIVORCED
<br />German / En lish MAR
<br />Richard B. Lockwood
<br />14a, USUAL OCCUPATION JGive kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15, EDUCATION (Specify only highest grade completed)
<br />of waking life, even if rebredl
<br />Elememary or Secondary 10 -121 College 11.4 or 5-1
<br />Accounting-Assistant Assistant
<br />Lockwood Accountin
<br />2
<br />IO. r.v nCn - rvHMC mn� 1 Mluu�t ui51 / MV 11-ICYI YIH,y I MIUULL MAIUNN SUHNAMIL
<br />. ____ _...
<br />Georg _... _....__W. Stevens
<br />CE . -_ . Elizabeth Bindernaugle
<br />9 18. WAS DEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME
<br />(Yes, no. or unk.) (It yes, give war and dates of services)
<br />no Steve Lockwood
<br />196. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO., CITY OR TOWN, STATE. ZIP)
<br />09 Robinhood Drive
<br />Beverl
<br />Hills Michigan
<br />48025
<br />PART PREGNANCY
<br />If
<br />. EMB LMER - SIGNATURE 8 LICENSE NO.
<br />J ' r
<br />"a. METWOO OF DISPOSITION
<br />21b. PATE
<br />21 c. CEMETERY OR CREMATORY NAME
<br />Yes No
<br />Yes L No,..
<br />� Burial 11 Removal
<br />09/2 2003
<br />Westlawn Memorial Park
<br />22a. FUNERAL E - NAME
<br />F-1 Accident F1 Undetermined
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STAYS -
<br />Cremation El Donauon
<br />M
<br />A fel- Butler- Geddes
<br />28a. INJURY AT WORK
<br />261 PLAC QF INJURY - At hom .farm, street, factory
<br />26g. LOCATION STREET OR R F D. NO. CITY OR TOWN STATE
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R,F.D, NO., CITY OR TOWN,
<br />STATE, ZIP)
<br />1123 West Second Street
<br />Grand
<br />Island Nebraska 68801
<br />28a. DATE SIGNED tifo.. Day. Yr.)
<br />-1 23. IMMEDIATE CAUSE
<br />(ENTER
<br />ONLY ONE CAUSE PER LINE FOR is). (b). AND (c))
<br />Interval between onset and death
<br />PART P� C J
<br />M
<br />a
<br />_
<br />I
<br />�(r.•/�_-
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Pay, Yr.J
<br />28tl, PRONOUNCED DEAD /HOUrI
<br />DUE T0, OR AS A CONSEQUENCE OF
<br />/
<br />5:03 a.m. M
<br />Interval between Onset and death
<br />M
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />28e, On the basis of examination and, or investigation, in my opinion death occurred at
<br />I
<br />f
<br />Interval between onset and death
<br />wl
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />If
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'S
<br />(Ages 10 -54) Yes Nb
<br />Yes No
<br />Yes L No,..
<br />25a.
<br />26b. DATE OF INJURY (Mo., Day. Yr.)
<br />26c. HpUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />F-1 Accident F1 Undetermined
<br />M
<br />0 Suicide ❑ Pending
<br />28a. INJURY AT WORK
<br />261 PLAC QF INJURY - At hom .farm, street, factory
<br />26g. LOCATION STREET OR R F D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />p Ice u4ding. etc. tSpecifyf
<br />27a. DATE OF DEATH (Md. Day. Yr.)
<br />/a 3
<br />28a. DATE SIGNED tifo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />n
<br />f (
<br />-
<br />M
<br />a
<br />_
<br />I
<br />27b. DATE SIGNED iMo.. Day.' Yc)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Pay, Yr.J
<br />28tl, PRONOUNCED DEAD /HOUrI
<br />'9
<br />&,.3
<br />5:03 a.m. M
<br />g�
<br />M
<br />`2 °
<br />27d. To the best of knowledge. death occurred lime. date and place and�jae to the
<br />28e, On the basis of examination and, or investigation, in my opinion death occurred at
<br />I
<br />f
<br />causelsl stated, �j /
<br />°
<br />the time, date and place and due to the causes) stated,
<br />r`
<br />ISi nature and Title) r
<br />ISi nature and Title)
<br />29. DID TOBACCO USE CO TRIBUTE TO THE DEATW
<br />30.a HAS ORGAN OR TISSUE DONATION CONSIDERED
<br />30.4 WAS CONSENT GRANTED?
<br />❑ YES , NO ❑ UNKNOWN Y
<br />(BBEEj�N
<br />❑ YES 17� NO
<br />[] YES N0
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type w Pdnt)
<br />Dr. Gordon J. Hrn' ek 72.9 Nortgh Custer Grand Island Nebraska 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />SEP 2 3 2003
<br />11 •
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