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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA -__1lFAj " _SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rgj *90 . ON FILL MTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE�TIft WcN IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />20050334) 7
<br />JUL 112002 r -_ . = AWtT s .c�oPER _-
<br />ASSIS�A�IT STATE REG /STftAO7l
<br />LINCOLN, NEBRASKA HEALTH AND HUIISANSERjgCfAt;YSTfW
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S �4NANCE_ `AND- SUffORT
<br />VITAL STATISTICS - '-_ -02 07829
<br />CERTIFICATE OF DEATH'
<br />`�- �� FIRST MI[IULE LAST 2 SEX 3 UATF OF DEATH lMOnfn. Day. Yoarl
<br />I - �
<br />_
<br />4. CITY AND STATE OF BIRTH 1lynot in USA.. name counlryl 5a. AGE - Last 8i Ihday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRCH /Mont, Oay. Year!
<br />IVrS 56. M(]S I DAYS 5f.. HOURS MINS
<br />Omaha, Nebraska 67
<br />February 28, 193
<br />y 5
<br />7 SOCIAL SECURTIY NUMBER " "' -' - -..
<br />R. PLACE OF DEATH
<br />508 -36 -3854 HOSPITAL inpatient OTHER Nursing Home
<br />8b. FACILITY -Name (Il nnnnstimrim. give street and number) ER Outpatient Residence
<br />St. Francis Medical Center
<br />UOA ❑ OtherfSW,tv,-
<br />-
<br />Grand Island Yes ® No Hall
<br />9a. RESIDENCE -STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Including Zip Codel uMITS
<br />=INSID
<br />Nebraska Ball Grand Island 2208 Cottonwood 68801 N-0
<br />io. RACP Ie.g., Wane. Black American Indian.
<br />etc I ISoe
<br />1
<br />�.
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Of wife. give maiden name!
<br />(rte
<br />ISpecdYl
<br />American
<br />❑ NEVER DIVORCED
<br />MARRIED
<br />Mary Ann Vetick
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<br />a
<br />_...
<br />15. EDUCATION (Specify only highest grade completedl
<br />Elementar Y11� c
<br />o ondary 1012) Cutlege l�.A p�!r -I
<br />Owner /Operator
<br />Keeshan Trucking
<br />18. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alfred Keeshan Florence Kelly
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT NAME - -
<br />IY nO Or unk.) (If yes. qwe war and dates pit services)
<br />Na ��_ Mary Keeshan
<br />1gb INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2208 Cottonwood Grand Island, NE. 68801
<br />n
<br />CJ'I
<br />r ®Burial Removal 2, 2002 Grand Island Cemetery_
<br />cn
<br />Apfel-- Butler -- Geddes ❑Cremaliorn ❑Donation Grand Island, NE
<br />�a i
<br />1123 West Second, Grand Island, NE 68801
<br />—•t
<br />PART
<br />1 I
<br />lal
<br />DUE TO, OR AS A CONSVFUENCE OF m µ Interval oetween onset anc neap,
<br />M
<br />UUF TO. OR AS A CONSEOl1ENCE OF Inerval oetwedn Ansel .r : ne,rll'
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Cpnddipn5 coniribWing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />II PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER''
<br />M
<br />.�...__.. TM ... —
<br />26a 266 DATE OF INJURY (Mn.. Day Yr,/ 26C HOUR OF INJURY 26d. UE S(:RIRF HOW INJURY UC(:l.1HHEU
<br />r—
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<br />Y
<br />Sue C tlo Penning 26e� IN.1l1RV AT WORK 2Fif PLLACE OF INJURY - At home. farm. Slieel. factory 2Fiy. LOCATION STRECI' UH H.F.D NO CIl Y UH 7 (]WN STA I'C
<br />building,
<br />❑❑ ❑ office etc (Sgacdy/
<br />Homicide Investlgatlpn yes No
<br />27a DATE OF DEATH (Mn Day. Yr.)
<br />28a DATE SIGNED (Mo Day Y,) 281, TIMF OF DEATH T
<br />6 -29 -02
<br />Vy
<br />� a �
<br />28c PRONOUNCED DEAD (Mn. Day. YrJ 280. PRONOUNCED DEAD (NOUrI
<br />27o DATE SIGNED lMo.. Day. Yr.l
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<br />7C
<br />7- -02 -02
<br />01:22 A.M.
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<br />21tl lu the hest pf my knowledge occurred at t time, date and place and due In the
<br />28e. Qn the basis of examination and or investigation, in my Opinlon death occurred at
<br />Slated.
<br />rn
<br />the time. date and place and due to the causels) stated.
<br />u,
<br />v
<br />(Signature and Tdle ►
<br />m .._._.. _........
<br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.6 WAS CONSENT GRANTED
<br />YES NO UNKNOWN ❑ YES X7 NO YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AT ICRNEY) /Type or Pnnry
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA -__1lFAj " _SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rgj *90 . ON FILL MTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE�TIft WcN IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />20050334) 7
<br />JUL 112002 r -_ . = AWtT s .c�oPER _-
<br />ASSIS�A�IT STATE REG /STftAO7l
<br />LINCOLN, NEBRASKA HEALTH AND HUIISANSERjgCfAt;YSTfW
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S �4NANCE_ `AND- SUffORT
<br />VITAL STATISTICS - '-_ -02 07829
<br />CERTIFICATE OF DEATH'
<br />`�- �� FIRST MI[IULE LAST 2 SEX 3 UATF OF DEATH lMOnfn. Day. Yoarl
<br />James Earl Keeshan Sr. Male June 29, 2002
<br />_
<br />4. CITY AND STATE OF BIRTH 1lynot in USA.. name counlryl 5a. AGE - Last 8i Ihday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRCH /Mont, Oay. Year!
<br />IVrS 56. M(]S I DAYS 5f.. HOURS MINS
<br />Omaha, Nebraska 67
<br />February 28, 193
<br />y 5
<br />7 SOCIAL SECURTIY NUMBER " "' -' - -..
<br />R. PLACE OF DEATH
<br />508 -36 -3854 HOSPITAL inpatient OTHER Nursing Home
<br />8b. FACILITY -Name (Il nnnnstimrim. give street and number) ER Outpatient Residence
<br />St. Francis Medical Center
<br />UOA ❑ OtherfSW,tv,-
<br />& CITY TOWN OR LOCATION OF DEATH - —'-' - - - - -- --
<br />8d INSIDE CITY LIMITS tle COUNT V QF DEATHf
<br />Grand Island Yes ® No Hall
<br />9a. RESIDENCE -STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Including Zip Codel uMITS
<br />=INSID
<br />Nebraska Ball Grand Island 2208 Cottonwood 68801 N-0
<br />io. RACP Ie.g., Wane. Black American Indian.
<br />etc I ISoe
<br />I1. ANCESTRY le.g Italian Mexican. German. etcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Of wife. give maiden name!
<br />(rte
<br />ISpecdYl
<br />American
<br />❑ NEVER DIVORCED
<br />MARRIED
<br />Mary Ann Vetick
<br />16i USUAL OCCUPATION lGrve kind of work done during most
<br />pfjvpn�r•••`rn, gyC�'rl relrredt
<br />146 KIND OF BUSINESS INDUSTRY
<br />_...
<br />15. EDUCATION (Specify only highest grade completedl
<br />Elementar Y11� c
<br />o ondary 1012) Cutlege l�.A p�!r -I
<br />Owner /Operator
<br />Keeshan Trucking
<br />18. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alfred Keeshan Florence Kelly
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT NAME - -
<br />IY nO Or unk.) (If yes. qwe war and dates pit services)
<br />Na ��_ Mary Keeshan
<br />1gb INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2208 Cottonwood Grand Island, NE. 68801
<br />20. EMjBMIEER - SIGNATURE B I ICENSE - I 21a METHOD OF DISPOSITION 21b. DATE 21C CEMETERY OR CREMATORY NAMC
<br />/Nn /U.
<br />r ®Burial Removal 2, 2002 Grand Island Cemetery_
<br />_July
<br />22a. FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CIIY OR TOWN STAtI
<br />Apfel-- Butler -- Geddes ❑Cremaliorn ❑Donation Grand Island, NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) "
<br />1123 West Second, Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib), AND (cl) t Interval hetween onset and deav
<br />PART
<br />1 I
<br />lal
<br />DUE TO, OR AS A CONSVFUENCE OF m µ Interval oetween onset anc neap,
<br />j Ibl I
<br />UUF TO. OR AS A CONSEOl1ENCE OF Inerval oetwedn Ansel .r : ne,rll'
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Cpnddipn5 coniribWing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />II PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER''
<br />4p [�
<br />. �.- `� (Apes 10-54) Yes ❑ No ❑ Yes .❑ NU ^ �I Ves ❑., N.
<br />.�...__.. TM ... —
<br />26a 266 DATE OF INJURY (Mn.. Day Yr,/ 26C HOUR OF INJURY 26d. UE S(:RIRF HOW INJURY UC(:l.1HHEU
<br />L ACCldent rI Undete —,,cd
<br />�`
<br />M
<br />Y
<br />Sue C tlo Penning 26e� IN.1l1RV AT WORK 2Fif PLLACE OF INJURY - At home. farm. Slieel. factory 2Fiy. LOCATION STRECI' UH H.F.D NO CIl Y UH 7 (]WN STA I'C
<br />building,
<br />❑❑ ❑ office etc (Sgacdy/
<br />Homicide Investlgatlpn yes No
<br />27a DATE OF DEATH (Mn Day. Yr.)
<br />28a DATE SIGNED (Mo Day Y,) 281, TIMF OF DEATH T
<br />6 -29 -02
<br />� a �
<br />28c PRONOUNCED DEAD (Mn. Day. YrJ 280. PRONOUNCED DEAD (NOUrI
<br />27o DATE SIGNED lMo.. Day. Yr.l
<br />27c T IME OF DEATH
<br />11 P�
<br />7- -02 -02
<br />01:22 A.M.
<br />Em o
<br />`a'
<br />_ _
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<br />�i
<br />M
<br />21tl lu the hest pf my knowledge occurred at t time, date and place and due In the
<br />28e. Qn the basis of examination and or investigation, in my Opinlon death occurred at
<br />Slated.
<br />r�
<br />'+
<br />the time. date and place and due to the causels) stated.
<br />nature and Title)
<br />(Signature and Tdle ►
<br />m .._._.. _........
<br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.6 WAS CONSENT GRANTED
<br />YES NO UNKNOWN ❑ YES X7 NO YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AT ICRNEY) /Type or Pnnry
<br />Thomas Wern r M.D. 2444 W. Faidley Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />32b DATE FILED OV REGISTRAR (Mo. Day. Yr.)
<br />A4� F(; ft
<br />JUL 1 0 2002
<br />I/ -
<br />LEGAL: Lot Twenty (20), in Capital Heights Eighth Subdivision, Hall County,f
<br />Nebraska,
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