|
H
<br />H
<br />m
<br />M h fS
<br />M
<br />MIDDLE LAST
<br />= D
<br />OF DEATH - lMOnm. Day. Year)
<br />Sandra
<br />Lou Naasz
<br />IS-'DATE
<br />Female
<br />October 16, 2002
<br />rn
<br />C) ---�
<br />(� Cn { C7
<br />m
<br />7C 2 ; _,_ r�
<br />-� o
<br />O,•�`C `
<br />-T, CO
<br />T z
<br />rn
<br />r
<br />oM
<br />r
<br />26f. PLACE OF INJURY - At home. farm. street. factory
<br />oMice bwldmg, etc. ISpeciyl
<br />503 -66 -9099
<br />1--a
<br />A
<br />Home
<br />333 S. Oak Grand Island NE ~-
<br />_ S
<br />Cn
<br />St. Francis Medical Center
<br />(n
<br />LOT 9, IN BLOCK 7, OF 90EHLER PLACE, IN THE CITY OF GRAND ISLAND,
<br />HALL COUNTY, NEBRASKA.
<br />WHEN THIS COPYCARR/ES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HU $FjWCgS
<br />Be. COUNTY OF DEATH
<br />SYSTEM, !f CERTIFIES T14E BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOW
<br />N
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST#q f i ,AWW
<br />27c TIME OF DEATH
<br />_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />9a. RESIDENCE -STATE
<br />A AQhEtf -` -.
<br />�
<br />OCT 2 5 2002 2 0 0 3 0 9 7 91
<br />ASSISTANT-ST ,� M
<br />9d. STREET AND NUMBER (Inc)uding Zip Code)
<br />_
<br />LINCOLN, NEBRASKA HEALTH AND HUAAAA
<br />Nebraska
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERiCI T
<br />_
<br />VITAL STATISTICS =
<br />CERTIFICATE OF DEATH 2
<br />1
<br />I
<br />m
<br />a �
<br />N
<br />o N
<br />W
<br />o
<br />CL0 2
<br />-J CD
<br />Ca
<br />1. DECEDENT - NAME FIRST
<br />MIDDLE LAST
<br />2. SEX _
<br />OF DEATH - lMOnm. Day. Year)
<br />Sandra
<br />Lou Naasz
<br />IS-'DATE
<br />Female
<br />October 16, 2002
<br />4, CITY AND STATE OF BIRTH (iynot iri U.S.A., name country/
<br />es 10 -54) Yes No
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Morten. Day. Year)
<br />Sb, MOS DAYS
<br />Sc. HOURS' MINB
<br />Pierre, South Dakota
<br />(vial 50
<br />October 19, 1951
<br />7. SOCIAL SECURTIY NUMBER
<br />Suicide 1-1 Pending
<br />8a. PLACE OF DEATH
<br />26f. PLACE OF INJURY - At home. farm. street. factory
<br />oMice bwldmg, etc. ISpeciyl
<br />503 -66 -9099
<br />Homicide Investigation
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home
<br />Home
<br />333 S. Oak Grand Island NE ~-
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (enot institution, give street and numberl
<br />St. Francis Medical Center
<br />28a. DATE SIGNED (Mo.. Day YO
<br />❑ 0OA ❑ Other(SpeC - ^'
<br />8c, CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island_,_ Nebraska
<br />N
<br />Yes 0 No ❑
<br />27c TIME OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />sib. COUNTY
<br />CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Inc)uding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />rrand Island
<br />333 S. Oak 68801
<br />Yea k] No
<br />10. RACE - (e.g,, White. Black. American Indian,
<br />11. ANCESTRY fe.g_
<br />Italian. Mexican, German, etc)
<br />12. ® MARRIED
<br />rl WIDOWED
<br />13. NAME OF SPOUSE /n wire. give maiden name)
<br />etc.) ISoecilyl
<br />White
<br />ISpec.tyl
<br />American
<br />NEVER
<br />MARRI
<br />I DIVORCED
<br />DeWa ne Naasz
<br />14a. USUAL OCCUPATION (Give kind of work abrie drrcing most
<br />DID TOBACCO USE CONTRIB O THE DEATH?
<br />14b. KIND OF BUSINESS INDUSTRY
<br />_
<br />30.b WAS CONSENT GRANTED'+
<br />15. EATION ISpecity only Nghest grade com)
<br />completed )
<br />of working life. even if refired)
<br />Homemaker
<br />x YES �NO
<br />Domestic
<br />Y,kn n' r Kin laq qJ . Co Av t- „d) raj F,J r A- (o &fr&3
<br />ElemeDUC
<br />le or Secondary 10.121 College 11 -4 01 5-1
<br />12
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Robert
<br />Brondel
<br />Bernice Wagner
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.) (if yes. give war and dates of services)
<br />No I
<br />DeWa ne Naasz
<br />3 outh Grand Island, Nebraska 68801
<br />20. LMER - SIGNATURE N ( //N/ /Q /�J 21a. METHOD OF DISPOSITION 21b. DATE T21c . CEMETERY OR CREMATORY NAME
<br />.i��'�1�� ® Burial ❑Removal Oct. 19, 2002 estl awn Memorial Park Cem.
<br />22a. FUNERAL OME AME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H. ❑Cremation El Donation Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />601 North Webb Road Grand Island, Nebraska 68803
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lab Ibl. AND (c)1 I Interval between onset and death
<br />1
<br />Ila)x I >< wk-S
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and dean,
<br />(b) X k r\t,oc--k�s ';)� h rs
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and deals
<br />I �
<br />I f»
<br />yOTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PR
<br />111 IF FEMALE. WAS THERE A
<br />GNANCY IN THE PAST 3 MONTHS?
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TOYy1- ICAL
<br />EXAMINER OR CORONER ? - - -'
<br />` /� 1� V
<br />it 1L � �V i � t
<br />Xs
<br />V
<br />X ` 1Q Ll TJ�j �� 1�� InV 1 r r
<br />es 10 -54) Yes No
<br />No
<br />r� Yes No
<br />26a
<br />26b bATE OF INJURY /Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Pt. took tylenol without realizing af�ct
<br />18 Accident Undetermined
<br />El
<br />9 -30 -02
<br />Unknown M
<br />on underlying alcohlic liver disease
<br />Suicide 1-1 Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE OF INJURY - At home. farm. street. factory
<br />oMice bwldmg, etc. ISpeciyl
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN -STATE
<br />Homicide Investigation
<br />Yes[] NOD
<br />Home
<br />333 S. Oak Grand Island NE ~-
<br />27a. DATE OF DEATH (MO.. Day. Yr)
<br />28a. DATE SIGNED (Mo.. Day YO
<br />28b TIME OF DEATH
<br />M
<br />N
<br />27b DATE SIGNED /MO.. Day. Yr)
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD (Mo. Day. Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />80
<br />1-+,33 M
<br />2 °
<br />M
<br />27d. To the best of my knowledge. death occurred at the tune, date and place and ue to the
<br />28e. On the basis of examination and or investigatan,.in my opinion death
<br />stated.
<br />° 5
<br />occurred at
<br />the time. date and due to the
<br />' Xcausefsl
<br />place and cause(s) stated.
<br />,
<br />(Si nature and Tole
<br />(Signature and Tiflel ►
<br />DID TOBACCO USE CONTRIB O THE DEATH?
<br />JO.a HAS ORGAN OR TISSUE DONATION BEEN CON DERED?
<br />_
<br />30.b WAS CONSENT GRANTED'+
<br />129
<br />❑YES NO ❑ UNKNOWN
<br />x ❑ YS NO
<br />x YES �NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( /Type or Print)
<br />Y,kn n' r Kin laq qJ . Co Av t- „d) raj F,J r A- (o &fr&3
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />OCT 21 2002
<br />U
<br />0
<br />
|