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Rev. 11197 `-
<br />200508112
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VI'T'AL STATISTICS
<br />CERTIFICATE OF DEATH
<br />cc
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<br />Lll,
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<br />II
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<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I Interval between Onset and death
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<br />PART PREGNANCY SIGNIFICANT CONDITIONS • Conditions conblbuting to the death but not related PART
<br />y , �+y� _ ^ ^ PREGNANCY
<br />II
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH !Month, pay. Year/
<br />N,.LtJ y 1/ 4
<br />Hollis Courtney Richter
<br />Male
<br />December 9, 1999
<br />2Ba.
<br />4. CITY AND STATE OF BIRTH !/roof h US.A.. name country/
<br />5a. AGE • Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (MOnfit, Day, Year)
<br />56. MOS. I DAYS
<br />5C. HOURS MINS.
<br />Suicide Pending
<br />❑ Homicide Investigation
<br />Gresham, Nebraska
<br />(Yt5.1
<br />83
<br />o
<br />June 30, 1916
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />508 -09 -7701
<br />HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home
<br />� I `q q
<br />❑ ER Outpatient ❑ Residence
<br />So. FACILITY -Name (Il not insNluflon, give street and number)
<br />M
<br />Tiffany Square
<br />❑ DOA ❑ Other (9pecdyt
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yc1
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />So. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />27d. To the best of ny knowledge. d t the time, pate anti place and duq to the
<br />causal stated.'/ \
<br />Y�
<br />Grand Island
<br />Yea ® No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />0b, COUNTV
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncluding Zip Cade)
<br />9e. INSIDE CITY LIMITS
<br />11 YES I /�L g NO ❑ UNKNOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2445 W.- LaMar Ave.
<br />Yeeil No ❑
<br />32e. REGISTRAR
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian, Mexican, German, etc)
<br />12. n MARRIED ❑ WIDOWED
<br />L�1
<br />13. NAME OF SPOUSE (It wile. give maiden name)
<br />etc.) IS ),
<br />Mite
<br />ISpecily)
<br />I American
<br />NEVER DIVORCED
<br />Alma M. Rahe
<br />142. USUAL OCCUPATION (Give kind of work dale during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />o/ working / /e. even it nedredl
<br />Pro uction Manager
<br />Manufacturing Co.
<br />Elemenla c ecdndary 10 -12) Coll ge 11 -4 or 5.1
<br />£I
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Frederick Richter
<br />Merle Ryan
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yee, no, or unk.)
<br />No
<br />(If yes. give war and dates of services)
<br />Alma Richter
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />5 W. LaMar Ave., Grand Island, NE 68803
<br />20ZEMLIMEn - SIGNATURE & LICENSE NO. II
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY, NAME
<br />(
<br />® Burial ❑ Removal
<br />Dec. 14, 1999
<br />Westlawn Memorial Park
<br />2a. FUNERAL Htl -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel - Butler- Geddes
<br />❑ cremation ❑ Donation
<br />Grand Island, NE
<br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, 7JP)
<br />1123 West Second, Grand Island, NE 68801
<br />23. IMMEDIATE ,SE ff �WJ7 -) �)ENNTER,ON�LLYO�NyE[ /C.�RUSE PER LINE FOR laa61^b),� AND D((oil I Interval between onset and death
<br />PART
<br />/ r �.c- Wiz/
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval b4twoon onset and death
<br />(b) I
<br />cc
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<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I Interval between Onset and death
<br />I
<br />ry
<br />PART PREGNANCY SIGNIFICANT CONDITIONS • Conditions conblbuting to the death but not related PART
<br />y , �+y� _ ^ ^ PREGNANCY
<br />II
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />I
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />N,.LtJ y 1/ 4
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yea No
<br />2Ba.
<br />26b, DATE OF INJURY (Ma. Day. Yr,)
<br />26d. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />❑ Homicide Investigation
<br />28e. INJURY AT WORK
<br />Yes ❑ Nd ❑
<br />Lp @@ pp p
<br />2fif, slice h %, INJURY twhoor' farm, street. factory
<br />/
<br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />26b. TIME OF DEATH
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<br />27b, DATE SIGNED (Mo.. Day. Yr)
<br />`IL�_ga
<br />27c. TIME OF DEATH
<br />/5.alo M
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yc1
<br />23d. PRONOUNCED DEAD (Hour)
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<br />9
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<br />27d. To the best of ny knowledge. d t the time, pate anti place and duq to the
<br />causal stated.'/ \
<br />Y�
<br />28e. On the basis of examination andror investigation, in my opinion death occurred al
<br />the time, date and place and due to the causefs) stated.
<br />ISI nature and Tllle o,
<br />signature and Title
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />11 YES I /�L g NO ❑ UNKNOWN
<br />❑ YES 9
<br />NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Prinl)
<br />Richard Fruehling M.D. 2116 W. Faidley, Grand Island, NE 68803
<br />32e. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr1
<br />FOR VITAL STATISTICS USE ONLY
<br />Place....................... A ................................ B ................................ C ......................... ....... D ................................ E .............. ............... ...Part II ...................... TMV...........................
<br />NSC....................... ........... ................................................................................ ............. -.... ..Census Tract No.
<br />\AlnrL
<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 />APFEL - BUTLER- GEDDES FUNERAL HOME
<br />iIMMIL � �
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