200311156 - Laserfiche WebLink

Browse

200311156 WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SERVICES SYSTEM RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE°C2imp SA%_r4Lf KITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL STAT1S CTIQ_NL S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE - _ - 5/12/2003 400RoR- ASS64TAi�IT STATE REGISI'Wilk LINCOLN, NEBRASKA HEALTHANDH®JY61NS1'T1I STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV FINAK_CE SPORT VITAL STATISTICS = =- -- 0 3 05240 r.r. n r1r1c1rn A TIC ^112 T%112 A I U 1. DECEDENT -NAME FIRST MIDDLE a LAST 2. SEX 3. DATE OF DEATH /Month. Day. Year) Opal Irene Marsh Female Aril 30, 2003 4. CITY AND STATE OF BIRTH (d not m U.S.A.. name counay/ Sa. AGE -Last BirMday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) (Yrs.l 0 i DAYS Sc. HOURS' MINS. Ma 2 1 1915 Stockham Nebraska O 7 8a. PLACE OF DEATH 7. SOCIAL SECURTIY NUMBER a Nursing Home HOSPITAL � Inpatient OTHER: r 506 -72 -9503 ER Outpatient Residence 8b. FACILITY - Name (d rol inshfigion, gnus street and number/ DOA Other (SW#vi r Tiffan S uare Care Center 8c. CITY. TOWN OR LOCATION OF DEATH gd INSIDE CITY LIMITS Be. COUNTY OF DEATH Yes 5d No ❑ Hall Grand Island AND ER /lncludYg Zip Code/ 9e. INSIDE CITY LIMBS 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9a. RESIDENCE -STATE Y� ®"°� Nebraska Hall Grand Island laine, 68803 10. RACE - Ie.q, White. Black. American Indian. 11. ANCESTRY le.g.. Italian. Mexican, German. etc) 12. O MARRIED 13. NAME OF SPOUSE Pl wile. give maiden name) t1705B NEVER R. Wayne Marsh etc.)iSpecify) (Specify) En 11th White 14a. USUAL OCCUPATION /Give kind d avrk done during most 14b. KIND OF BUSINESS INDUSTRY TION (Specily only highest a eompleted) tary or Secondary 10 -121 Colts" 11 -4 or 5 -1 o/ agrking /i le, even i /relined/ Homemaker Dome tic 12 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Wilbur Willcock Ne ie Bird 18. WAS DECEASED EVER 1N U.S. ARMED FORCES? 19a INFORMANT (Yes. )Yes, no. or unk.) Itl yes. give war and dates of services) R. Wa ne Marsh no 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP) 1705 South Blaine Street r nd I lan eb 21 a. METHOD OF DISPOSITION 21b. DATE c. CEMETERY OR CREMATORY NAME 121 20. EMBALMER - SIGNATURE 8 LICENSE NO. 2003 Cedarview Cemetery Ma 3 ❑ ® Burial Removal , 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 2a FUNERAL HOME -NAME ❑ ❑ gal. Nebraska Crematin Doni han Apfel- Butler - Geddes ME ADDRESS ISTREET OR R.F.D. NO.CITY OR TOWN. STATE, ZIP) West Second Street, Grand Island Nebraska 68801 death I Interval between onset and (ENTER ONLY ONE CAUSE PER LINE FOR (a). It)). AND (c)) TE CAUSE �I Interval between onset and death R ORAS ACOONSEEQQUENCE OF' I Interval between onset and death . OR AS A CONSEQUENCE OF: I i..�.,r �J U � Idl Wr)r\' OTHER SIGNIFICANT CONDI S - Conditions contributing to the death but not related PREGNANCY FEMALE. THE PAS THERE MONTHS? 24 AUTOPSY OR CORONER? PART PART "-f II (Ages 10.51) Yes No Yes No Ves No 26a 26b. DATE OF INJURY (Ma. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW IN, JRV OCCURRED Accident n Undetermined - M Suicide Pending 26e. INJURY AT WORK 261. PLAe E OIFF INJURY ,S 11cog1/ , farm. street. factory dfieee bu '0' 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes 11 No 0 28a. DATE SIGNED (Mo.. Day. Yr.) 28b. TIME OF DEATH 27a. DATE OF DEATH (Mo.. Day. Yr.) r nil 30, 2003 r �" M 28c. PRONOUNCED DEAD IMO.. D.Y. Yr.) 28d PRONOUNCED DEAD (Fburl ys 27b. DATE SIGNED (Mo.. Day. Yr.) 27c. TIME OF DEATH d < a 6 2003 2:05 8= M basis causafsl in lated. ion death occur at the trims, dnteoand place and due o investigation, f k . dear// occurred at thatime, date and place � to the 67�. �- o a e •� I Si nature and Title itle 29. DID TOBACCO USNTH15 TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONAT ION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES �� YES UNKNOWN YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) island, Nebraska 68803 32b. DATE FILED BY REGISTRAR (Ma. Day. Yr./ 32a. REGISTRAR _ - / Y 9 2003 Lf