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co 20050314'7 R W. 1119 ATE OF NEBRASKA - MPARTbIENr OFD HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT STATVThCS CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2• SEX 3. DATE OF DEATH /MMdr. Day. Yar) Velaura Minnie Matilda Frauen Female March 14, 2004 A. CITY AND STATE OF BIRTH /d ncr H USA, same e«r+ryl Sa. AGE -Lad BkihUV UNDER 1 YEAR UNDER 1 DAY a. DATE OF BIRTH /AMndt Day yw Rural Merick County, Nebraska (Yral 83 Mos' I H01 MINS. November 24, 1920 7. IAL SECWRTIY NUMBER Ba PLACE OF DEATH 505 -.16 -0853 NOSVRAL• (� Irlpadera OTHER: ❑ Nursing Home SkFACANfY - Name / Ndditti71rd011.pMca9MlandrirM6Ml ❑ EROu"bort ❑ Raallome Bryan LGH - East [] ODA ❑ aw.r /��' Be. CITY. TOWN OR LOCATION OF DEATH !d. INSIDE CITY LIMITS 8a. COUNTY OF DEATH Lincoln Y„ 2 ,,b ❑ Lancaster 9a RESIDENCE - STATE 90. COUNTY &. CITY. TOWN OR LOCATION W. STREET AND NUMBER llncludbtg 270 COORJ 9e. IN CITY LIMITS Nebraska Hall Grand Island 13516 Farmstead Road, 68801 Yee ❑ NO 10. RACE rfeg, While, Black. Amarkoam Ir d on, 11. ANCESTRY lo.g.. Ubm Meaicin• Oertnwt NCI 12. ❑ MARRIED ® WIDOWED 13. NAME OF SPOUSE I// woo. 9" flwopn name) a� ' derlhan NEVER 0 IVORCEO John Delbert Frauen (Deceased) 0 144. USCUPATION J0"U1dWMans'densCxkVmrul 1W. KIND OF BUSINESS INDUSTRY 15. EIXICATION (Specify only stgrade COwWwl I�we' ss"�is� ant Hospital ��ury «�� 10.121 Gw.91 n.. «5•+ C1B• FATHER - NAME FIRST MIDDLE •LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Arthur (NMI) Ueckert Sophie (NMI) Ashweige O e 1& WAS DECEASED EVER IN U.S. ARMED FORCES? 1Sa. INFORMANT -NAME N l Y Pl o . W Wk) Id yes. yew war mid dale, a eewim) Gary J.A. Frauen c E 19b, INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO, CITY OR TOWN. STATE 21PI tv d 3524 Farmstead Rd., Grand Island, Nebraska 68801 20. EM LMER - SIG TORE S LICENSE NO. 2/a METHOD OF DISPOSITION :�Ik DATE 21c, CEMETERY OR CREMATORY NAM 1037 (�(8ixw �Re al 3/19/2004 Grand Island City Cemetery Lu E I FUNERAL HOME • NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE w 1 leine Funeral Home Denow Grand Island, Nebraska 7+ 22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO_ CITY OR TOWN, STATE, IIP) CL 3213 W North Front St Grand Island, NE, 68803 'G 2'.L IMMEDIATE CAUSE IENTER C*4Li yriE. CAUSE PE; L r.s ivl°• :ii• i�w Ai:� �iyi I Interval hntween Doan and deals W y PART I IN r nary Z LL DUET N I Interval oalween onsel end death 1 and death onset I knerval betw CO) �1 DUE O.OR AS A CONSEOUENCF OF: een I t Ice PART OTHER 95NIFICANT CONDITIONS - Caldho s to to deal+ bU nOl Mtled PART III IF FEMALE WAS THERE A 24. AUTOPSY 26. WAS CASE REFERRED TO MEDICAL Renal y PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? 11 Renal failure Yee IJO Yea NO . (Agee 1Q -541 Y" NO 2Ba. 28b. DATE OF MIJURY No.. Dry. Yr,J 26c. HOUR OF INJURY 28d. DESCRIBE HOW &JRY OCCURRED ❑ Acriderd ❑ UndNermirwd M Stack% ❑ Pam" Mo. INJURY AT WON( ze1. P�IeC�_QF �PMU�AY i�lw�• Ia�•+leeL Iitlorl' 28¢ LOCATION STREET OR R.F.D. NO, CRY OR TOWN STATE HOmiclde kw"Option Yee ❑ Ne wM� 2EATH lAla• Day. 17 2Ba DATE SIGNED /ANN. pay. Yr.l 2Bb. TIME OF DEATH h 14, 2004 M ED !AA•x. Day. Yr,J 27C. TIME OF DEATH 2BC. PRONOUNCED DEAD lAla.. DAY, Yrl 2Bd PRONOUNCED DEAD !lNOwl F -04 Q.2/ M M B d my atl1 occunod M IN C daN end dace enl dos b lte $ Wrle, diN P tlus b tM u�usels opindn death Occurred u me beat, 01 andor kweefillaeom In my led• - Isamu- Tile / end Tide 29, DID TOBACCO USE CONTNB THE DEATH? 30•s HAS ORGAN OR TIME DONATION BEEN CONSIDERED? 50A WAS CONSENT GRANTED? ❑ YES ❑ NO a UNKNOWN ❑ YES [a NO ❑ YES ® ND 31, NAME AND ADDRESS Or CERTIFIER IPHYSICUW, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI lTWw a Prind Scott P. Liggett, M.D., 307 N 46th St., Lincoln NE 68503 32b. DATE FILED BY REGISTRAR (Mo.. Osy. Yr./ 32a REGISTRAR FOR VITAL STATISTICS USE ONLY Place.......... ............A ... .............................13 ",............................. 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