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200311980 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN- SERWCES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REEEEEEEE WTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIBS *! 1!s THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ " ` DATE OF ISSUANCE = _ LAN APR 1 0 2002 ASSIffAfIi GISTRAR LINCOLN, NEBRASKA HEALTH AND h"#AN- S- SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SINMCES FWAgCE AND SUPPORT VITAL STATISTICS n n r CERTIFICATE OF DEATH - = T 02 lJ `7 [) 1 DFCEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Month. Day. Year/ Cecelia Burns Wa over Female I March 22 2002 4 CITY AND STATE OF BIRTH Moot in USA.. name countryl 5a. AGE - Last Binhday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Monet. Day. Year) Sb MOS DAYS Sc HOURS' MINS Yuma Count Colorado III IF FEMALE. WAS THERE A (Y's l 89 March 10, 1913 L�iGi 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 506 -20 -2582 EXAMINER OR CORON ? HOSPITAL Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient Residence 8b. FACILITY -Name (N not institution. give street and number) 1 St. Francis Medical Center Yes No DOA ❑ Other /Spec,tyi 8c. CITY. TOWN OR LOCATION OF DEATH 26t. HOUR OF INJURY 8d INSIDE CITY LIMITS i 8e. COUNTY OF DEATH Grand Island Yes Ed No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY M 9c, CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Lp Code) 9e INSIDE CITY LIMITS Nebraska Hall 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Wood River 1411 Walnut 68883 Yes ® No ❑ 10. RACE - (e g., White. Black. American Indian, 11. ANCESTRY le .g.. Italian. Mexican, German, etc) 12. E:] MARRIED O WIDOWED 13. NAME OF SPOUSE (If wile. give maiden name/ etc.) ISpeci ) W ite (Specify) Irish NEVER DIVORCED MARRIED Thomas J. Wagoner (dec) 14a. USUAL OCCUPATION /Give kind o/ work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed( Elementary or Secondary 10 -121 College If -4 or 5�1 of working life, even d refired) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD [Mo.. Day. Yr.) Bookkeeper ggo Ordinance Plant 4 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME John C. Burns Lena Moffitt 18. WAS DECEASED EVER IN U.S. ARMED FORCES? ° 19a. INFORMANT -NAME )Yes no, or unk.) pt yes. give war and dates of services) causelsl stated. l �pwle�dg - -' ° No I Jud Wagoner 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 1716S. Curtis Street Grand Island NE 68803 20, EMB ER - StGN TURF 8 . /� y O EN CONSIDERED? 21 a. METHOD OF DISPOSITION 21b DATE EMETERY OR CREMATORY NAME ZICENS I N OY ® Burial ❑ Removal 3/25/02 Fsctc. 's Cemeter 228. FUNERAL HOME - FAAE 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE A fel Funeral Home ❑ O1emation ❑ Donation Wood River NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP) 411 West 11th St. P.O. Box 126 Wood River NE 68883 23. IMMEDIAIE CAUSE (ENI EH ONLY ONE CAUSE HEH LINE FUH (a). 101. AND (C)) Interval between onset ano aealn PART I J // /�/J 1 DUFIO, OR AS ONSEOUENCE OF. Interval between onset and death c� � n /n L I (bl (J`Cj�jAA C DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death a I �,/ v (� �G1,>) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS? EXAMINER OR CORON ? (Ages 10 -54) Yes No Yes No Yes No 26a 26b. DATE OF INJURY /Mo.. Day Yr/ 26t. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED nAccident 1-1 Undetermined M • Suicide ❑ Pending 26e. INJURY AT WORK 26f. PLACE OF, INJURY - At hom ,farm. street, lactory building. 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE • Homicide Investigation Yes[] No ❑ office etc. (Specify, 27a. DATE OF DEATH /MO. Day. Yr.) 28a. DATE SIGNED /MO. Day Yr .I 28b TIME OF DEATH is March 22 2002 M 4 t ° 27b. DATE SIGNED (Mo. Day Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD [Mo.. Day. Yr.) 28d. PRONOUNCED DEAD /HOUrI ggo March 2 002 5:45 AM M S° 27tl. 7o the best o'-Y' �� eath occurred at the ti ,date and Dlace and due to the 28e. On the basis of examination and: or investigation, in my opinion death occurred at ° ° causelsl stated. l �pwle�dg - -' ° the time, date and place and due to the causelsl stated. (Si nature and Tit e) ► (S nature and Title) ► 29. DID TOBACCO USE CONT UTE/TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION EN CONSIDERED? 30.b WAS CONSENT GRANTED' YES O ❑ UNKNOWN ❑ YES I N OY ES ! NO 31 NAME AND ADDRESS OF RTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type of Pfrh John Wagoner 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR tMo.. Day Yr.) • 6V, kA APR 8 2002 1/