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Rev 11.97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />2 0 0 5 0 4 7 0 7 VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />t DkCFDENTNAMF. FIRST MIDDLE
<br />d DEATH !Month. Day. Y860
<br />q Clare
<br />Female
<br />lie 27 2003
<br />__ __
<br />4 UTV ANU STATE pacquenh Zinn S.Aamt cp�nt, 5a .AGE -Last BlnnuT"SUNDER1 YEAR 6A DATE
<br />y/ y y E OF BIRTH !Month. Day Year/
<br />[Y,s l 5h MOs. DAYS 5C. HOURS MINI,
<br />Holyoke, Massachusetts 42 Jun, 25, 1961
<br />aa. PLACE OF DEATH
<br />7. SOCIAL SECURTIY NUMBER �r�
<br />-7
<br />018 -52 --2774 HOSPITAL_ ® Inpatenl OTHLH ❑ Nurslny Humc•
<br />-- - -
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<br />❑ ❑
<br />tld FACII..II'Y . Name (//nor,ristayrion, give street and numbar) ER Uulpalianl Rnsltlence
<br />St. Francis Medical Center ❑ DOA ❑ De, errsprnr ,------ .�,- ._.---- ..._..�_...
<br />ac CIl'Y TOWN OR LOCATION OF DEATH
<br />ad INSIDE CITY LIMITS
<br />ae. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9a HE SIGFNCk - STATE
<br />9b. COUNTY
<br />9C C11 Y. TOWN OR LOCATION
<br />NUMBER n nduding ZrQ C,c
<br />9e INSIDE CI lV LIMITS
<br />26g. LOCATION STREET OH F,F.D. N0. CITY OR TOWN STATE
<br />28a. DATE SIGNED (M0. (Jay Yr) l 28b. TIME OF OEA1N
<br />Nebraska
<br />Hall
<br />Grand Island
<br />=dTF1E1'T
<br />edling Mile Ct.
<br />Yes ® No ❑
<br />10 RACE -ley.. White. Black. American Indian.
<br />11. ANCESTRY Ie.g. Italian. Mexican, German, elcl
<br />12. [7 MARRIED F-1 WIDOWED
<br />13 NAME OF SPOUSE il! wJe. yrvW rllarderAnlb/
<br />M
<br />atn) ISoec,tyl
<br />White
<br />speCrlyl
<br />Czech /French
<br />NEVER DIVORCED
<br />A
<br />William J. Tow_s_ley
<br />28c. PRONOUNCED DEAD (Mo. Day. Yr)
<br />14a. USUAL OCCUPATION !Give kindW work done during most
<br />146 KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISueaiv only n,ghest grade culnpleted)
<br />_
<br />Dan lenlaly 01 Secondary IU 12) College II -4 ut 5.1
<br />B .
<br />or LltirArng /le, Over) l/,9erad)
<br />Clerk
<br />Motel
<br />12th Grade
<br />16. FATHER -NAME µ_FIRST MIODLE LAST
<br />17�MOTHER .. FIRST MIDDLE MAIDEN SURNAME
<br />270 To ilia best of my knowledge. death occurred at the time, date and place and due to the
<br />Andy Dudas
<br />Lillian ne_sl_a_uriers
<br />18. WAS DECEASED EVEH IN U.S. ARMED FORCES?
<br />_-
<br />INFORMANT .NAM[:
<br />the lime, data and place and due la the causes) stated.
<br />(Yea n, nr unk I III yes give wat and dales of Services)
<br />7
<br />No - - - - --
<br />I
<br />William J. Towsle
<br />S ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />19b INFORMANT MAILING ADDRESS I5TREET OR R.F.D NO, CITY OR TOWN. STATE ZIP)
<br />A YES NO ❑ UNKNOWN
<br />114 N. Seedling Mile Ct. Grand Nebraska 68801 _ _____•_
<br />❑ YES ® NO -
<br />20 EMS E - SIGNAYy 8 LI SE NO.
<br />���,�I �r117�
<br />_Island,
<br />21a METHOD OF DISPOSITION
<br />21b. DATE
<br />21C CEMETERY OR CREMATORY NAME
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<br />[] adrlal �] Hen,dyal
<br />June 30, 2003
<br />Westlawn Crematory
<br />22a FUNERAL IIOME AME
<br />_
<br />21d CEMETERY ORCREMATORY LOCATION CITY OR TOWN STATE
<br />XC,amalron L1 Donal-'
<br />Grand Island, Nebraska
<br />Livingston- Sondermann F.H.
<br />220. FUNERAL HOME ADDRESS [STREET OR R.F,D. NO.. CITY OR TOWN, STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
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<br />LJ. IMMCUTA 1 C I:AUSk Ira rcn vnr-+ vrvc �.nu,�r= rr=n �rrvr= run ra, lul, r.rvy lull " "v'• ^ "' ^^� ^ "" ^ ""' """•
<br />PAHI
<br />k P`_','nCre_c(: 6 C_ C ai\ C',,
<br />w DUE TO, OR AS A CONSEQUENCE OF
<br />Interval between tinsel and tlP.alh
<br />I61
<br />_DUE
<br />Interval between Onsel and death
<br />ICI
<br />......, I
<br />24 AUTOPSY
<br />25. WAS CASF REFERHED TO MEDICAL
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />II "J'Ages
<br />10 -541 Yes No
<br />Yes No
<br />_
<br />Yes No
<br />2ba
<br />286. DATE OF INJURY (Ma. Day, Yr./
<br />26C. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN.,JRY OCCURRED
<br />Acrldent L1 WrdelemUned
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<br />Swede L� P indln9
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<br />L _.I Hwmclua Investigation
<br />26e. INJURY AT WORK
<br />Yes ❑ No ❑
<br />26f. PkA ff RF. INJURY •gt hog. larm. steel. factory
<br />d ce ding. etc. / Pact
<br />26g. LOCATION STREET OH F,F.D. N0. CITY OR TOWN STATE
<br />28a. DATE SIGNED (M0. (Jay Yr) l 28b. TIME OF OEA1N
<br />µ
<br />27a. DATE OF DEATH /Mp.. Day. Vr.J
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<br />27b. D SIGNED /MU.. D-, It r.)
<br />27c. TIME OF DEATH
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<br />28c. PRONOUNCED DEAD (Mo. Day. Yr)
<br />28d. PRONOUNCED DEAD /Hood
<br />//ATE
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<br />270 To ilia best of my knowledge. death occurred at the time, date and place and due to the
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<br />2Be. On me oasis el axammation and nr rnuastgaton, m my opinion dean occurred al
<br />i, l'"` 151 slated, ['�
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<br />the lime, data and place and due la the causes) stated.
<br />ISI nuse and Tnto ►
<br />(Signature and Title .�
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<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />S ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.6 WAS CONSENT GRANTED'!..
<br />A YES NO ❑ UNKNOWN
<br />7311a
<br />❑ YES NO
<br />❑ YES ® NO -
<br />31 NAME AND ADDRESS OF CERTIFIER )PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY[ liype� or Pn
<br />T C� 'tQ
<br />3p l (Q � r �c'r��e Ave Avg - �a
<br />32 a REGIS TRAR
<br />326. DATE FILET) BY REGISTRAR /MO., Day. Yr.J
<br />FOR VITAL STATISTICS USS ONLY
<br />Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV...........................
<br />NSC............. ...................... ... ... ............................... ........... : ...................... ............................................................................................... ................. .........................Census Tract No.
<br />Work............................................. ... ............................... .............................................................. ........................... ................. ---- ........ ... .... ............................ ................ ....................... .... ......
<br />UC..................................... ............................... _..,..........,........,............................................................................................................................ ...............................
<br />Reject........................................................................................................................................................ ............................... • - ................. ...............................
<br />... -. _.. - arri..rd wIt" soy Ink on rOCycltid P.P.. 6 ... -.
<br />1 hereby certify this to be a true and coma copy of the original
<br />filed with the State of Nebraska
<br />=enc � day of
<br />Notary Public
<br />TERRY L. !.OSCHEN
<br />rNEa - MY COMMISSION EXPIRES
<br />knrnnr ;' -
<br />"�!" "` May 2, 2006
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