|
A"
<br />4 J
<br />bleu, 11/97
<br />N
<br />C
<br />O
<br />0
<br />T
<br />n
<br />c
<br />7
<br />0
<br />U
<br />c
<br />� E=
<br />to
<br />m
<br />z°
<br />w E
<br />C G
<br />U.(
<br />U ,v
<br />I11 N
<br />L
<br />LL .n
<br />O�
<br />CN
<br />C U)
<br />Q 8
<br />Z LL
<br />frJ
<br />1:0
<br />a10054f 449
<br />STATE OF NEBRASKA- DEPARTMENT' OF HEALTH. AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />C FRTIFiCATE OF DEA'T'H
<br />ECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year/
<br />Marian Jeanne Berr an
<br />Female
<br />.Tune 23, 2003
<br />4. CITYIAND STATE OF BIRTH 111 not In U.S.A. name country)
<br />6a. AGE - Last Bldhday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />MOS, PAYS
<br />'
<br />5c. HOURS' MINS,
<br />Wilmette, Illinois
<br />(Yrs.) 56.
<br />80
<br />November 27, 1922
<br />7. SOCIAL SECURTIY NUMBER
<br />Be, PLACE OF DEATH
<br />Inpatient OTHER: L1 Nursing Home
<br />r,o y!TAL:
<br />342 -14 -2557
<br />❑ ER Outpatient ❑ Residence
<br />fib. FACILITY• Name Ilfno/insfifutlon,gives)reel and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specilw
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />ad. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑x No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />96. COUNTY
<br />9c. CITY, TOwN OR LOCATION
<br />TREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />712 Kuestex .Lake 68801
<br />Yes ❑ ND�
<br />10. RACE - (e.g., White. Bla0k, American Indian.
<br />11. ANCESTRY le.g.. Italian, Maviean, German, etc(
<br />12. ® MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (p wile. give maiden name)
<br />etc.) (Specify(
<br />White
<br />(Specify(
<br />French
<br />NEVER DIVORCED
<br />A
<br />Robert H. Berryman
<br />AL OCCUPATION /Give kind of work dons during most 146.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only higheal grade completed)
<br />Elemenyaryor Secondary 10 -12( Colleges (1 -4 or 5.1
<br />orking life, even if retired)
<br />Home Maker
<br />Domestic
<br />12
<br />F_16.FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Arnold Ellert
<br />Elizabeth Howard
<br />DECEASED EVER IN U.S. ARMED FORCES?
<br />i9a. INFORMANT -NAME
<br />o. or unk.) (If yes. give war and dates of services(
<br />no
<br />Robert H. Berr an
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.P.D. NO., CITY OR TOWN. STATE. ZIP(
<br />#12 Kuester Lake Grand Island Nebraska 68801
<br />20. EMBALMER • SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />TORY , NAME
<br />(�
<br />=UNMCAnatomical
<br />❑ Burial ❑ Removal
<br />June 23 2003
<br />Board
<br />22a. FUNERAL HOME • NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />A fel- Butler - Geddes
<br />❑Cremation Donation
<br />Omaha Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP(
<br />1123 West Second Street Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR le)• (b). AND (c)1 Interval between onsel and death
<br />l
<br />PART /� �.y� A J s ��
<br />I (�ririrr
<br />(al I
<br />• DUE TO, OR AS A CONSEQUENCE OF, Interval between onset and death
<br />y�J
<br />(b) CIS C/'1'a"�tlV I �•-. �i� Y F � /fC
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />Idl I
<br />OTHER SIGNIFICANT CONb171DN5 • Condlticns contributing to the death 6u1 not related PART
<br />P
<br />III IF FEMALE, WAS THERE A
<br />EGNANCV IN THE PAST 3 MONTHS?
<br />24. AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />PART
<br />k ��q
<br />(Ages lO-54) Ye9 No
<br />Y96 Na
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /Mc.. day. Yr.J
<br />26c. HOUR OF INJURY
<br />HOW INJURY O URRED
<br />Accident � Undetermined
<br />M
<br />126d.DESCRIBE
<br />❑ Sulelde Pending
<br />26a. INJURY AT WORK
<br />LLqq pp �t
<br />26f. affiva fullding�etRY , farm, atreal. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑, No ❑
<br />rYl
<br />27a- DATE OF DEATH (Ma. Day. Yr)
<br />28a, DATE SIGNED (Mo., Day. YnJ
<br />286• TIME OF DEATH
<br />1..,,Qo03
<br />� �
<br />M
<br />r i
<br />G
<br />27b. DATE SIGNED (Mo., Day. Yr.J
<br />27(;. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Ma. Day, Ycl
<br />26d, PRONOUNCED DEAD (Hour)
<br />M
<br />i2
<br />c
<br />27d. To the bps) of my knowle ge, at occurre��6yt ih�te, d tl place and due to the
<br />causafs) staled.
<br />29a. On the basis of examination and,or Investigation, In my opinion death occurred at
<br />ihp time, date and place and due Iv Ih0 causes) staled.
<br />(Si nature and Title ►
<br />Si nature and Title
<br />29. DID TOBACCO USE CONTRIBUTE Tp THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.6 WAS CONSENT GRANTED?
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES IX,! NO
<br />❑ YES NO
<br />31, NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdnf)
<br />Dr. David R. Colan, 729 North Custer, Grand Island, Nebraska 68803
<br />32a, REGISTRAR
<br />326. DATE FILED SY REGISTRAR IMa. Day. Yr,)
<br />FOR VITAL STATISTICS USE ONLY
<br />Place ....................... A ................................ B ............... ., ............... C ............ , ............ , ...... D ................................ E ................................ Part Ii ................... ,. .TMV ..................
<br />.........
<br />NSC...................................................................................:..............................................:........................................................ ............................... .........................Census Tract No.
<br />Work....
<br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE
<br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA.
<br />FEL- BUTLER DES FUNERAL HOME
<br />
|