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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/&=� Tzx)A& 1 WICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. `
<br />DATE OF ISSUANCE+
<br />ANLEYS. tOOPER
<br />11/5/2004 2 0 0 5 0 4 0 9 3 ASS1$TA�,9TA -MGI RAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERW qeS_ SmM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN MRV97SF$T)WE ACAS S?jfF:-_)RT
<br />VITAL STATISTICS - n i1
<br />C'F.RTTxTf ATF. f1F T)FATTT n /I 1 ? n 1 1 z4
<br />1. DECEDENT -NAME FIRST MIDDLE LAST ;
<br />ay Vea/
<br />Nancy Lynn Glass
<br />29, 2004
<br />4. CITY ANp STATE OF BIRTH ll)not in U.S.A.. name country) 5
<br />5a. AGE - Last Btnhday U
<br />UNDER 1 YEAR D
<br />;SEX qMINI 7
<br />7DEATH a
<br />Sheboygan, Wisconsin 8
<br />(Yrs.l
<br />85 e
<br />er 20, 1938
<br />■ 7. SOCIAL SECURTIY NUMBER 8
<br />8a. PLACE OF DEATH
<br />1 555 -52 -1391 -
<br />HOSPITAL: Inpatient OTHER: Nursing Home
<br />8b. FACILITY - Name (!)not institution, give street and number) E
<br />ER Outpatient El Residence
<br />St. Francis Medical Center ❑
<br />❑ DOA Other /
<br />/$pecdvi
<br />8c. CITY, TOWN OR LOCATION OF DEATH e
<br />ed. INSIDE CITY LIMITS 8
<br />8e. COUNTY OF DEATH
<br />Grand island Y
<br />Yes a No U M
<br />Mall
<br />9a. RESIDENCE - STATE 9
<br />9b. COUNTY 9
<br />9c, CITY. TOWN OR LOCATION 9
<br />9d. STREET AND NUMBER /including Zip Codel 9
<br />9e. INSIDE CITY LIMITS
<br />Nebraska H
<br />Hall G
<br />Grand Island 4
<br />4348 W. Capital Ave. 68803 Y
<br />Yes ® No
<br />10, RACE • (e.g., While, Black, American Indian. 1
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 1
<br />® MARRIED ❑WIDOWED 1
<br />13. NAME OF SPOUSE (it wr/e. give maiden name)
<br />etc.) (Specify) (
<br />(Specify)
<br />112, ®
<br />John tale$$
<br />14a. USUALOCCUPATION (Give kind of work done during most 1
<br />14b. KINDOFBUSINESSINDUSTRY 1
<br />15. EDUCATION (Specify only highest grade completed)
<br />• Loan Manager F
<br />Finance �
<br />Elementar or Secondary (0.12) College 11'•4 or S'P
<br />i 16, FATHER -NAME FIRST MIDDLE LAST 1
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />John Papendieck R
<br />Ruth Loebel
<br />• 18. WAS DECEASED E
<br />EVER IN U.S. ARMED FORCES? 1
<br />19a. INFORMANT - NAME
<br />(Yes. no, or unk.) (
<br />(If yes. give war and dates of services)
<br />NO J
<br />John Glass
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP)
<br />4348 W. Capital Ave. Grand Island, Nebraska 68803
<br />20. EMBALMER - SIGNATURE d LICENSE NO, 2
<br />21 a. METHOD OF DISPOSITION 2
<br />21b. DATE =
<br />RY OR CREMATORY. NAME
<br />Not Embalmed 7
<br />7 Burial ❑Removal
<br />Oct. 29, 20 N
<br />=Central R
<br />22a. FUNERAL HOME • NAME 2
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home�X C
<br />Cremation ❑ Donation G
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS )STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />1123 W. 2nd St, Grand Island, Nebraska 68801
<br />21 ._-
<br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la)• (b), AND (d)) Interval between onset and dealn
<br />'(al MYOCADIO INFARCTION ; IHH
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />A ATHCOSCLEROSIS 30 YR
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />KIT nnM WTAI
<br />" A V T n
<br />PAR? OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related II IF FEMALE, WAS THERE A 24 AUTOPSY 35. WAS CASE REFERRED TO MEDICAL
<br />11 f p r NANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />RECTAL T U M O R D R O N C H TUMOR C y A 10 -54) Ye s Na X Yes No Yes No
<br />28a. 284, DATE OF INJURY (Ma. pay. Yc) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined M
<br />❑ Suicide ❑ Pending 26a. INJURY AT WO 281. PId.ACE� C�F INJURY -SP.t home, (arm, street, factory 26g. LOCATION STREET OR R.F,D, NO, CITY OR TOWN STATE
<br />❑ ❑ OE owe
<br />ding, etc. / paddy)
<br />Homicide Investigation Yes No
<br />27a. DATE OF DEATH (Mo.. Day. Yr.) 2aa. DATE SIGNED (Mo.. Day. Yr.) 28b. TIME OF DEATH
<br />October 29, 2004 s�
<br />Sa M
<br />27b. DATE SIGNED Mo.. Da Yrl 27c. TIME OF DEATH `
<br />i Y 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour)
<br />OCT 29 , 2004
<br />M
<br />° 27d. To the best of my knowledge. death occurred at the time, date place and due to the 12 ¢ 0 28e. On the basis of examination and•or Investigation, in my opimon death occurred at
<br />cause(s) stated. 8 the time, date and place and due to the cause(s) stated.
<br />(Signature and Title) ISi nature and Tide ►
<br />29. DID TOBACCO USE CONTRIB THE DEATH 30.a 7HA R GAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />11 YES ® NO ❑ UNKNOWN YES © NO ❑ YES ® NO
<br />Larry Hansen, M.I. 301 West Faidley Grand Island, Nebraska. 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) NOV 4'2004
<br />Larry Hansen, M.I. 301 West Faidley Grand Island, Nebraska. 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) NOV 4'2004
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