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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND KAEXVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL REIPINRff-bIME-W"
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST /G$�TI(N; i "M-,H0
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ -
<br />a�
<br />. ;Jr
<br />DATE OF ISSUANCE -
<br />JP 4 ZOOZ .20050 5 AIyLEYS.GQO
<br />ASSIsTAf# STATE)wa=
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVIC M: 'W
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESTWANMA W- SORT
<br />VITAL STATISTICS 12 10011,
<br />CERTIFICATE OF DEATH
<br />i OLCE'DENT - NAME FIRST
<br />MIDDLE LAST
<br />24 AUTOPSY
<br />2'$EX .3
<br />DATF DEATH /Mnntn 0,,, "earl
<br />rs"
<br />William
<br />Joseph Haney
<br />EXAMINER OR CORONER'
<br />Male
<br />August 26, 2002
<br />4. CITY AND STATE OF BIRTH 111 not in C!S.A.. name country)
<br />Yes r_] No
<br />5a. AGE Last Birthday
<br />UNDER I
<br />YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH !Month. Day Year)
<br />Grand Island, Nebraska
<br />Homicltle InvestigaUpn
<br />IYrsl 80
<br />5h MOS
<br />DAY$
<br />5c HOUM'': MINS.
<br />27a DATE OF DEATH (Mo.. Day. Yr)
<br />_
<br />29. DATE SIGNED (Mn. Day. Yr)
<br />28b TIME OF DEATH
<br />August 26, 2002
<br />;,
<br />May 241 1922
<br />7. SOCIAL SECURTIV NUMBER
<br />�=
<br />8a. PLACE OF DEATII
<br />506 -18 -7859
<br />2711. DAIS SIGNED (Mo.. Day Yr.J
<br />HOSPITA_t.
<br />Inpatient UIHER ❑ Nurs,ng Home
<br />28d. PRONOUNCED DEAD (Hour)
<br />a
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name Ill not rnsliN(an, give street and numW
<br />St. Francis Medical Center
<br />❑ DOA ❑ other iSpeclty;
<br />BC. CITY TOWN OR LOCA1ION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e COUNTY OF DEATH
<br />ca and due to the
<br />28e On the basis of examination and or invest)gat,on, in my opin,on death occurred at
<br />the Ume. date and place and due to the causelsl stated,
<br />°
<br />Grand Island
<br />Yes ® No 1:1
<br />IS nature and Title ►
<br />Hall '
<br />ga. RESIDENCE- STATE
<br />9b. COUNTY
<br />E] YES NO ❑ UNKNOWN
<br />9c. CITY, TOWN OR LOCATION
<br />❑ YES NO
<br />9 NUMBER (dro/udlrrg Zip Code)
<br />9e INSIDF, CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />E. Airport Road 68803
<br />Yes ❑ No
<br />10. RACE - (e.g.. White. Black. American Indian.
<br />11. ANCESTRY le.
<br />g.. Italian. Mexican. German, elcl
<br />12. MARRIED
<br />r"'7 WIDOWED
<br />13 NAME OF SPOUSE (// wde. g/va maidan narna/
<br />etc.) ISpeclfy)
<br />White
<br />(Specify)
<br />American
<br />NEVER
<br />❑ NEVER
<br />gIVORCFp
<br />Ina M. Northhouse
<br />14a. USUAL OCCUPATION (Grve kir dof w k cone during most
<br />14b. KIND OF SUSINESS INDUSTRY
<br />1S. EDUCATION (Specify only highest grade completed)
<br />d working life, even d retired)
<br />Contractor
<br />Plaster
<br />Elementary or Secondary p- 121 College 11 4 or 8 -I
<br />11
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOIHF,H
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Joseph
<br />IF]
<br />Mary Rose
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES ?
<br />19x. INFORMANT - NAME
<br />T
<br />'Yes. no. o(unk.) I flf yes. give war and dates of services)
<br />Yes WWII Jul 29 1942 to November
<br />111] 945
<br />Ina M. Haney
<br />IM INFUHMANI MAILIN(jAUIJHtSS
<br />20.
<br />IS I HhE 1 OR H.F.O. NO., CITY OR 1 OWN. ST A I E. ZIP)
<br />168 E. Airport Road, Grand Island, NE 68803
<br />#1071 2 f1 ate. (METHOD OF DISPOSITION 21b. DATE
<br />.` IXI Burial F-1 Removal August 29. 2002
<br />22a FUNERAL HOME - NAME -
<br />All Faiths Funeral Home
<br />21C. CEMETERYORCRFMATORY NAME
<br />Westlawn Memorial Park Cemeteq
<br />1210 UtML TrHY OR CREMATORY LUCAI ION CITY OR TOWN STATE
<br />[❑ Cremation ❑ Donal,on Grand Island. Nebraska
<br />-
<br />2211 FUNERAL HOME ADDRESS (STREET OR R.F.O. NO .CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St. Grand Island, NE 68801
<br />23 IMMEDIATE CAUSE
<br />(ENTER ONLY ONE CAUSE PER LINE FOR )al. Ibl. AND Icll ' Interval between tinsel -n dual
<br />PART
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />DUF T0. OR AS A CONSEQUENCE OF Interval bwwean o yet and dean
<br />i
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED lq MEDICAL
<br />PART
<br />II
<br />PRFGNANCY IN THE PAST 3 MONTHS
<br />EXAMINER OR CORONER'
<br />��I It
<br />)Ages 10 -54) Yes L] No
<br />Yes ❑ Nu u
<br />Yes r_] No
<br />28a
<br />261. DATE OF INJURY (Mo.. Day. YrJ 26r.. HOUR OF INJURY god. DESCRIBE HOW IN.,JRY OCCUHRED ,
<br />❑ Accident ❑ Undetermined
<br />M
<br />n Suicide F-] Pending
<br />2$e. INJURY AT WORK 26f PLLACE OF INJURY - AI nome. tams. slreel. Iactory 28y. LUCAT iON STREET OH H.F.U. NO. (;I1 Y OH TOWN
<br />Homicltle InvestigaUpn
<br />❑ ❑ otlice building. etc /Speedy)
<br />Yes No
<br />27a DATE OF DEATH (Mo.. Day. Yr)
<br />29. DATE SIGNED (Mn. Day. Yr)
<br />28b TIME OF DEATH
<br />August 26, 2002
<br />;,
<br />�=
<br />M
<br />2711. DAIS SIGNED (Mo.. Day Yr.J
<br />27c TIME OF DEATH
<br />28C PRONOUNCED DEAD (Mo. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />a
<br />�
<br />-ll `L-
<br />1:37 P. M
<br />M�
<br />27d To the best of my knowledg , th occurred all time, dal
<br />causelsl stated.
<br />ca and due to the
<br />28e On the basis of examination and or invest)gat,on, in my opin,on death occurred at
<br />the Ume. date and place and due to the causelsl stated,
<br />°
<br />ISignature and Title
<br />IS nature and Title ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.1 wA5 CONSENT GRANTEp7
<br />E] YES NO ❑ UNKNOWN
<br />❑ YE$ 1
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P /nil W
<br />Dr. David Colan, 729 N. Custer Ave., Grand Island, NE 68803
<br />32m, REGISTRAR _ 32b. DATE FILED BY REGI Da cJ
<br />I � 1�;6'kn . ___ ___ s�
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