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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 t I6gLEWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS: SECTION.-WNICK/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />2 0 0 5 0 4 2 2 4 ANLEY"OOPER- =:
<br />OCT 2nQ� ASSISTANTSTAWE`R-E-670- lAl�'
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN. SERwIcES sy4o Al
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FTAIANCE ANIXAWPeRT ,
<br />VITAL STATISTICS 4 7 2
<br />CERTIFICATE OF DEATH --
<br />1 OFCEDENT. NAMC FIRST MIDDLE LAST 2 SE .x 3. DATE OF DFATH r1Trr,7!h !)itv Year)
<br />Lois J
<br />4. CITY AND STATE OF BIRTH (Il not in U.S.A.. name count(y)
<br />Stella, Nebr
<br />7. SOCIAL. SECURTIY I LIMBER
<br />506 -30 -5800
<br />8b. FACILITY . Name Of not mshtutron, give street and number)
<br />St. Francis Skilled Care Unit
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />9a. RESIDENCE
<br />Catholos Female October 3, 2002_
<br />5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month, Day. Year/ ..,_.
<br />(Vr51 5b MOS I DAYS Sr. HOURS MINS
<br />�� January 7, 1930
<br />ad.
<br />Yes I ••. 1 No
<br />CITY, TOWN OR LOCATION
<br />82 PLACE OF DEATH
<br />HOSPITAL'.
<br />... .... - --
<br />❑ Inpatient
<br />215d. DESCRIBE HOW INJURY OCCURRED
<br />❑ FR Outpatient
<br />❑ DOA
<br />INSIDE CITY LIMIT'S I
<br />Be. COUNTY Ol DLF
<br />Nebraska I Hall I Grand Island
<br />16 RACE - (e g„ White. Black. American Indian. I 11, ANCESTRY (e.g., Italian, Mexican, German, etc) 12. © MARRIED
<br />etc.) (Specify) Tom.,' (Spee,fy) NEVER
<br />Whet@ American LAARRIEQ
<br />144. USUAL OCCUPATION (Grve kind of work done during most 14b. KIND OF BUSINESS INDUSTRY
<br />of working life, even it retired)
<br />Nurse Medical
<br />16 THE NAME FIRST MIDDLE LAST 1 17 MOTHER
<br />Jack NMI Ramel
<br />OTHER Nursing Home
<br />- ❑ Residence
<br />C Othel 1SIR41 ,, led
<br />Ski.l.._.,..._ - - Care -- - --
<br />9d. STREET AND NUMBER tjIN SI DE CITY LIMITS
<br />4237Pennsyly aniaAve• s No ❑
<br />❑ WIDOWED 13 NAME OF SPOUSE /l! wAe. give maiden rlarne/
<br />DIVORCED Jimmie A. Catholos
<br />15. EDUCATION (Specify only highest grade completed)
<br />F, lememary or Secondary D -12) 2 CWlegtise. 0 -4 or 5 -)
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Lena NMI Chamberlain
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? r9a INFORMANT -NAMF
<br />(Yes . nr unk.) (If yes. give war and dales of services)
<br />No Jimmie A. Catholos
<br />19b. INFORMANT MAIL ING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />. .. ,, Nebraska 68803
<br />4237 Pennsylvania Ave ,__ Grand Isl and. _.._ rs
<br />_ _ —
<br />2�FLMER - SIG ATURF & LICENSE NO 21 a. METHOD OF DISPOSITION 21b. DATC 21c CRY OR CREMATORY NAMF
<br />-l") D` e�,rZ 4 j� [9 Burial ❑ Removal Oct. 5 2002 Grand Island City Cemetery
<br />22a. tNNEHAL HOME - NAMt \, 21d CEMETERY OR CRFMATORY LOCATION
<br />Kleine Funeral HOme ❑ Cremation ❑ Donation
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />3213 W. North Front Street, Grand Island, Nebraska ...
<br />2B' IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. fb)• AND (ell
<br />PART
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />CITY OR I OWN .....,.,.__ -__ STATE
<br />Grand Island. Nebraska
<br />Interval between onset and death
<br />^. r pJ-Ywj
<br />I Interval between onset and death
<br />(bl
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART � ) 1 ',A. _
<br />DI C+7 itty t (T(")
<br />Interval between onset and deem
<br />PART III IF FEMALE. WAS THERE A '2W Al1TOPSY 1� WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONFR
<br />(Ages 10 -541 Yes No Yes No Yes No
<br />26a. 26b DATE OF INJURY (Mo., pay. Yr.) 26c. HOUR OF INJURY
<br />215d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F-] Undetermined
<br />M
<br />URY - Al home. farm. Sheer. factory 26g. LOCATION STRFE.T OH H F.U. NO. CITY OR TOWN STATE
<br />Suicide Pending 26e. INJURY AT WORK 261. PLACE OF 19J _
<br />❑ ❑ office building (Spcity'
<br />171 Homicide Investigation Vey No
<br />2y DATE OF DEATH (Mo. Day. Yr,)
<br />x
<br />28a. UAiC SIGNED (Mo.. Dal,. Yr) 26b TIME OF DEATH
<br />3 a
<br />ti
<br />M
<br />{z)
<br />6
<br />?t DATE SIGNED (Mo.. Day Y0 TIME OF DEATH -
<br />0 28c PRONOUNCED DEAD (Mo.. Day. Yr) 28d. PRONOUNCED DEAD (H(
<br />a
<br />M
<br />_
<br />c
<br />° 2 d. To th best of my knowledge. death occurred at the time, date and place and due to the
<br />~ a
<br />' ° 28e. Orr, the basis W akamination and or investigation, in my opinion death cccurred al
<br />cause(s) Stated, p� g
<br />�7
<br />the time, date and place and due to the cause(s) stated.
<br />IBignalure and Title) ► ' / u�-
<br />(S�9nature and Title ►
<br />�p
<br />X. DID TOBACCO USE CONTRI uTE TO THE DEATH? a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3D WAS CONSENT GRANTED?
<br />❑ YES NO ❑ UNKNOWN ❑ YES NO ❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER [PHYSICIAN, CORONER'S PHVSICWN OR COUNTY ATTORNEY[
<br />(Type or Print)
<br />K. Morse MD, 729 N. Custer Grand
<br />Island, Nebraska 68803 _ _
<br />_Anne
<br />32a FCGISTRAR
<br />`
<br />32b. DATE FILED BY REGISTRAR (Mo. Day Yr.)
<br />- -- .._._ OCT 9 2002 ....._.....
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