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WHEN Trrs copy cARe1ES ofo aEAL of TI M NEDRAaKA NEALIN Afl�UMwRV10Es
<br />SYSTEII� ?CERTIFIES THE BELOW -T"E-A-rRVE-COPY OF THE ORIGINAL I�C$RO WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_ SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORD&
<br />DATE OF ISSUANCE
<br />ANLEY S CO
<br />OPi9R
<br />AUG 2 0 2003 mEwsm- An
<br />LINCOLN, NEBRASKA HEAL THANJjt4& MAIVI3ERV10E#SY M/
<br />200311203
<br />STATE OF NEBRASKA- DEPA1t7MO1I0f MALTH AND ADMAN SOtVlL�S
<br />Y 10 9 5 3
<br />[fAL STATISM
<br />CERTIFICATE OF DEATH
<br />f. DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3 DATE OF OEAT14 M No OW Hsay
<br />Mm Esther La ftreen
<br />Famak
<br />September 21,2M
<br />A. CITY AND STATE OF BIRTH Aaan USA. n&W MWW 5a. AGE - W b* ft
<br />UNDER t YEAR
<br />o u:
<br />S. DATE OF BIRTH ,Mi0t1aIL DIr VOW
<br />5b MOS DAYS
<br />m
<br />=
<br />r^
<br />D
<br />N
<br />7 SOCIAL SEGURTP/ NUMBER
<br />b PLACE OF DEATH
<br />SW22 -8369
<br />HoSNTAL 0 1 plan a OTHER 0 mwwl9 HOnM
<br />O
<br />G ER OtIpYara ® Readwe
<br />C
<br />Z
<br />n
<br />0 DOA D OOw Awe"
<br />T
<br />-
<br />_
<br />z m
<br />9m. RESIDENCE -STATE 9b CGLWTY if CRY. TOWN OR LOCATION
<br />ell
<br />Nebraska Iitdl Grand Island
<br />2 wa IN Na 0
<br />10 RACE - (e9- W1bM. 8tath Anw can qlm.
<br />11. ANCESTRY log MMaaR. MaiCan. Oat1Aal. ara 72 � O W(DORED 1 13 ' A„E OF SPOUSE rra,aR IetiAluMen AIR11F.
<br />ak.! ISoaC1Y1 Wbl[e
<br />ISpatAYl ♦ merkan f NEVER --Rc- erend Voluey D L�+sem
<br />N
<br />146 USUAL OCCUPATION•tGrol kmd0f w_" d0m dwM maN
<br />Z c
<br />nNN
<br />0fa0#ar7pMaMRr1aanAAl Homemaker
<br />Dorsestic
<br />EIMIxrWY «Sw"Id V 10 -121 f� 11 an -,
<br />1i9
<br />��
<br />Frank VanCkove Lora Manger
<br />c n
<br />EVER IN U.S. ARMED FORCES? t9a INFORMANT - NAME
<br />(Yes. ,0 0, urwo
<br />I No
<br />ff fA Yee. 97Ya w aItl OMs of tlwlae „I —
<br />I Reverend yolaey D Wgreen
<br />-
<br />19b. WFORMANT M0ULII3 ADDRESS !STREET OR R F D NO- CITY OR TOWN STATE. M
<br />2656 O'Flannagan Street, Grand Island, Nebraska 6W3
<br />2D EMBALMER - SIGNATURE B LICENSE NO
<br />210 METHODOFDLSPOgTQN J 21b. DATE 21C CiMTERYORCREWiOFI NAW
<br />Not Embalmed
<br />❑ &rlal Hsnwm {ISepteutber 22, 2002 } • Westiawn Cremm"7
<br />121a CEMETERY OR CREMATORY LOCATION CITY OR IONA STATE
<br />22a FUNERAL HOME - NAME
<br />All Faiths Funeral Home
<br />®(/WprO^ ❑ Dew Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR RFD NO CRY OR TOWN STATE. TIP!
<br />2929 S. Locust St. Grand Island, Nebraska 68801
<br />23 IBMEDIATE CAUSE IIFNTER ONLY ONE CAUSE PER LIE FOR ,ai %). AND (0 —! - kvwa l balrean «leaf a- over
<br />PART
<br />I l /� • I li. /- i # A 4,4 T A.444 .r l
<br />DUE TO. OR AS A CONSEOUENCE OF eIW ,r 1311101WOFUN anti q,ya
<br />:3
<br />-
<br />10
<br />PART OTHER S1(iNlFrANT CONDITIONS - CbnSWO ow*40lanpID ax-OSa0 dA rot m Me
<br />PART R IF F£W4E. WAS THERE A ?a AUTOPSY
<br />25 WAS CASE REFHNEO TOlEDG1l
<br />I A -
<br />PREGNANCY IN THE PAST 3 MONTH$'+ I
<br />EXA~R OR CORONER^
<br />rte
<br />Yes ❑ NOm
<br />26a 1{ 26b DATE OF MUURY Mb. Dav Yr.) 26c HOUR OF RWURY 1 280 DESCRIBE HOW IiJURY OCCURRED
<br />❑ AcC,daM ❑ Unaetnnune0
<br />M
<br />�❑ Su ,de ❑ Pa.&.. 1269 RA,tURV AT WORT( 26f oL11CLOF tUJU� !At M/. to —Streel iW”
<br />Mm.
<br />X- Id &r
<br />269 LOCATX.Yv STREET OR qFD NO GIIY OR TOVW SiiiF --
<br />II ❑ HpgyGtle „M,y„�, Y„ ❑ ❑
<br />U-)
<br />T— 1
<br />283 DA�w Dav v:: 1 266 TAME OF DEATH
<br />September 21, 2002
<br />:.
<br />�\
<br />28t PRONOUNCED DEAD -N+ Day Y., 1 280. PRONOUNCED DEAD n,blr!
<br />(�
<br />4:00 P M
<br />�z
<br />S
<br />? M
<br />9 770 7o ow b" of Afgwlee9e octu�eC ante. and dw to Rid
<br />C.ca.Wa,.�
<br />_ _ _
<br />260 Or. vw bias of ev anon. n o«�
<br />o
<br />cr'
<br />me t•me, Gals ar70 dace ir4: sue r a1s cwsala; atale0
<br />I care arw Toe
<br />fSoma" Aw Tdol ►- .. .
<br />29 CID tQBACCp USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED, 30L WAS CONSENT GRANTED'
<br />YES NO 0 UNKNOWN [] YES PQ
<br />NO YES NO
<br />I `---
<br />i
<br />37 NAME AND ADDRESS CEM1TiER 7PHYSICUN. CORONERS PHYSICIAN OR COUNTY ATTORNEY, '7rAe a A',AI
<br />David Co1an , M.D., 729 North Custer Avenue, Grand Island, Nebraska 68903
<br />LOT 2, BLOCK 32, ORIGINAL
<br />TOWN OF
<br />GRAND
<br />ISLAND,
<br />HALL COUNTY, NEBRASKA
<br />WHEN Trrs copy cARe1ES ofo aEAL of TI M NEDRAaKA NEALIN Afl�UMwRV10Es
<br />SYSTEII� ?CERTIFIES THE BELOW -T"E-A-rRVE-COPY OF THE ORIGINAL I�C$RO WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_ SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORD&
<br />DATE OF ISSUANCE
<br />ANLEY S CO
<br />OPi9R
<br />AUG 2 0 2003 mEwsm- An
<br />LINCOLN, NEBRASKA HEAL THANJjt4& MAIVI3ERV10E#SY M/
<br />200311203
<br />STATE OF NEBRASKA- DEPA1t7MO1I0f MALTH AND ADMAN SOtVlL�S
<br />Y 10 9 5 3
<br />[fAL STATISM
<br />CERTIFICATE OF DEATH
<br />f. DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3 DATE OF OEAT14 M No OW Hsay
<br />Mm Esther La ftreen
<br />Famak
<br />September 21,2M
<br />A. CITY AND STATE OF BIRTH Aaan USA. n&W MWW 5a. AGE - W b* ft
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />S. DATE OF BIRTH ,Mi0t1aIL DIr VOW
<br />5b MOS DAYS
<br />se. M1ouRS MINE.
<br />Beaver City, Nebraska I nrs • 78
<br />J aauaNtY 27, 1924
<br />7 SOCIAL SEGURTP/ NUMBER
<br />b PLACE OF DEATH
<br />SW22 -8369
<br />HoSNTAL 0 1 plan a OTHER 0 mwwl9 HOnM
<br />G ER OtIpYara ® Readwe
<br />ab FACILITY - N&M /dnofrMlalblR Dn+aaeeMana Huntley
<br />2656 WFlannogan Street
<br />0 DOA D OOw Awe"
<br />Bt. CITY TOWN OR LOCATION OF DEATH a0 INSIDE CRY LIMITS
<br />fe COUNTY OF DEATH
<br />Grand Island Yea © No
<br />Ball
<br />I
<br />9m. RESIDENCE -STATE 9b CGLWTY if CRY. TOWN OR LOCATION
<br />N STAEETANDUAMA /ac"ftJIp Cone/ !r W6CE MY LIMM
<br />Nebraska Iitdl Grand Island
<br />2 wa IN Na 0
<br />10 RACE - (e9- W1bM. 8tath Anw can qlm.
<br />11. ANCESTRY log MMaaR. MaiCan. Oat1Aal. ara 72 � O W(DORED 1 13 ' A„E OF SPOUSE rra,aR IetiAluMen AIR11F.
<br />ak.! ISoaC1Y1 Wbl[e
<br />ISpatAYl ♦ merkan f NEVER --Rc- erend Voluey D L�+sem
<br />N
<br />146 USUAL OCCUPATION•tGrol kmd0f w_" d0m dwM maN
<br />+AYiBKro OF SUbiVESS WOUSTRY
<br />15 EbJCATION 1Sp oly ONy ay c«"Ofto
<br />0fa0#ar7pMaMRr1aanAAl Homemaker
<br />Dorsestic
<br />EIMIxrWY «Sw"Id V 10 -121 f� 11 an -,
<br />1i9
<br />18. FATHER -NAME FIRST MIDDLE LAST +7 MOTHEF, FIRST MME MAIDEN $U(WIyE
<br />Frank VanCkove Lora Manger
<br />14 WAS DECEASED
<br />EVER IN U.S. ARMED FORCES? t9a INFORMANT - NAME
<br />(Yes. ,0 0, urwo
<br />I No
<br />ff fA Yee. 97Ya w aItl OMs of tlwlae „I —
<br />I Reverend yolaey D Wgreen
<br />-
<br />19b. WFORMANT M0ULII3 ADDRESS !STREET OR R F D NO- CITY OR TOWN STATE. M
<br />2656 O'Flannagan Street, Grand Island, Nebraska 6W3
<br />2D EMBALMER - SIGNATURE B LICENSE NO
<br />210 METHODOFDLSPOgTQN J 21b. DATE 21C CiMTERYORCREWiOFI NAW
<br />Not Embalmed
<br />❑ &rlal Hsnwm {ISepteutber 22, 2002 } • Westiawn Cremm"7
<br />121a CEMETERY OR CREMATORY LOCATION CITY OR IONA STATE
<br />22a FUNERAL HOME - NAME
<br />All Faiths Funeral Home
<br />®(/WprO^ ❑ Dew Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR RFD NO CRY OR TOWN STATE. TIP!
<br />2929 S. Locust St. Grand Island, Nebraska 68801
<br />23 IBMEDIATE CAUSE IIFNTER ONLY ONE CAUSE PER LIE FOR ,ai %). AND (0 —! - kvwa l balrean «leaf a- over
<br />PART
<br />I l /� • I li. /- i # A 4,4 T A.444 .r l
<br />DUE TO. OR AS A CONSEOUENCE OF eIW ,r 1311101WOFUN anti q,ya
<br />bl
<br />DUE TO. OR AS A CONSEOUENCE OF ... Inlel.y 71a1taan nasal anti neie
<br />10
<br />PART OTHER S1(iNlFrANT CONDITIONS - CbnSWO ow*40lanpID ax-OSa0 dA rot m Me
<br />PART R IF F£W4E. WAS THERE A ?a AUTOPSY
<br />25 WAS CASE REFHNEO TOlEDG1l
<br />I A -
<br />PREGNANCY IN THE PAST 3 MONTH$'+ I
<br />EXA~R OR CORONER^
<br />(A9e910.5.11 Yes NJ YeS No
<br />Yes ❑ NOm
<br />26a 1{ 26b DATE OF MUURY Mb. Dav Yr.) 26c HOUR OF RWURY 1 280 DESCRIBE HOW IiJURY OCCURRED
<br />❑ AcC,daM ❑ Unaetnnune0
<br />M
<br />�❑ Su ,de ❑ Pa.&.. 1269 RA,tURV AT WORT( 26f oL11CLOF tUJU� !At M/. to —Streel iW”
<br />Mm.
<br />X- Id &r
<br />269 LOCATX.Yv STREET OR qFD NO GIIY OR TOVW SiiiF --
<br />II ❑ HpgyGtle „M,y„�, Y„ ❑ ❑
<br />DATE OF OEATH !Ab Dar Yr)
<br />T— 1
<br />283 DA�w Dav v:: 1 266 TAME OF DEATH
<br />September 21, 2002
<br />:.
<br />28t PRONOUNCED DEAD -N+ Day Y., 1 280. PRONOUNCED DEAD n,blr!
<br />276 DA: E STONED IMo Div n, 27c TIME OF DEATH
<br />jig-
<br />4:00 P M
<br />�z
<br />S
<br />? M
<br />9 770 7o ow b" of Afgwlee9e octu�eC ante. and dw to Rid
<br />C.ca.Wa,.�
<br />_ _ _
<br />260 Or. vw bias of ev anon. n o«�
<br />We
<br />me t•me, Gals ar70 dace ir4: sue r a1s cwsala; atale0
<br />I care arw Toe
<br />fSoma" Aw Tdol ►- .. .
<br />29 CID tQBACCp USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED, 30L WAS CONSENT GRANTED'
<br />YES NO 0 UNKNOWN [] YES PQ
<br />NO YES NO
<br />I `---
<br />i
<br />37 NAME AND ADDRESS CEM1TiER 7PHYSICUN. CORONERS PHYSICIAN OR COUNTY ATTORNEY, '7rAe a A',AI
<br />David Co1an , M.D., 729 North Custer Avenue, Grand Island, Nebraska 68903
<br />W"
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<br />CD
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<br />N.
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