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WHBV 57IIS COPY CABS THE RAISED SEAL OF THE NEBRASKA STATE D9ft6M49Vr W -U IELTH, <br />/T CERTIFIES THE BELOW TO SEA TRUE COPY OF AN OMONVAL RECORD DN-*XE iVn ->fif 3 -TATS <br />DBRARTMENT OF HEALTH, B0lt®14V'Of WTALATATISTICS, WHICH IS P&LE" 0fiWiMYfOR <br />VITAL RECORDS. - <br />DATE OF ISSUANCE <br />FEB 2 7 1997 _ -STAN <br />9?-- iV ZjZ3 ! ASSISTANT STATERE6619TRAR <br />LINCOLN, NEBRASKA NEBRASIbt r HEAt rH <br />STATE OF NEBRASKA - DEPARTMENT OF HEACU <br />200312135 BUREAU OF VITAL STATISTICS __ <br />CERTIFICATE OF DEATH <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2, SEX <br />3. DATE OF DEATH (MOnth. DRY Yea/ <br />T. Frank Conti Carr <br />Male <br />February 13, 1997 <br />4. CITY AND STATE OF BIRTH IN not h U.S.A. name COUnl / <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Abrlift Day. Yowl <br />Ste. MoS. DAYS <br />5c. HOURS' MINS <br />Williamsburg, Pennsylvania <br />(Ym.l <br />86 <br />August S t 2 9, 1 9 1 1 <br />g <br />L SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />HOSPITAL: Inpaaem OTHER: © Nursing Home <br />402 -20 -3663 <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name /prat kWhftlia4 9n1e secret std numbed <br />❑ DOA ❑ Dater ISpecdyl <br />Lakeview Nursing Center <br />8:, CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS OF DEATH <br />r8e.OUNTY <br />I Yes ❑X No ❑ Hall <br />Grand Island CITY LIMITS <br />ga. RESIDENCE - STATE 9b. COUNTY 9C. CRY. TOWN OR LOCATION 9d. STREET AND NUMBER (krckrdkVZrp Code/ <br />714SIDE, <br />YeS No ❑ <br />Nebraska Hall Grand Island 407 E. Nebraska 68801 <br />10. RACE - ((e.g.. While. Black. American kdian. 11. ANCESTRY (e.g.. Nallan. Mexican. German, erc) 5. E MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /N wAe grYS maiden mane/ <br />iiISDecMl (SPOCMI NEVER DIVORCED <br />White American Lillian E. Krz <br />d) <br />148. USUALOCCUPATION (GivekndwwLWdamdungmast 14b. KIND OF BUSINESS INDUSTRY , 15. EDUCATION ISpecfi'o^IY 9rstlaconrpeladl <br />o( wvrking cite, men it r~) Ebm entary or Secondary 10 -12) yea (I -40,5 <br />Heating /Cooling 3 Years <br />Owner 0 erator <br />I-MI MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />16. FATHER -NAME <br />Antonio NMI Conti <br />t8. WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT -NAME <br />((Yes. M. or urty IN yes. give war and dates of servC981 <br />NO NIA <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP) <br />407 E. Nebraska, <br />20. EMBALMER - SIGNATURE b LIOENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 2tc. CEMETERY OR CREMATORY - NAME <br />X Burial ❑Removal Feb. 18, 1997 Valle View Cemetery <br />❑ <br />220,, NERAL HOME -NAM 21d. CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE <br />Kleine Funeral Home ❑c -'adn ❑°a' Genoa, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R. F.D. NO.. CRY OR TOWN. STATE. ZIP) <br />3213 W. North Front St., Grand Island 6ggn3 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lab (b). AND (cl) I Interval between onset and death <br />I <br />PART <br />(at Interval I Interval between onset and death <br />DUE TO, OR AS A CONSEQUENCE OF <br />1 <br />(b) I kterval between onset and ceam <br />DUE TO. OR AS A CONSEQUENCE OF: I <br />I <br />ICI PART 11, OTHER SIGNIFICANT CONDITIONS - Conditions c"bUltin9 to tla death but not related <br />THE PAST THERE A AUTOPSY EXAMINER OR CORON TO MEDICAL <br />PART PREGNANCY N <br />N -541 Ye s No Yes No es <br />26b. DATE OF INJURY (Ate.. Day Yr./ <br />2fx HOUR OF INJURY <br />I(Ages <br />DESCRIBE HOW INJURY OCCURRED <br />ACCidenl El Undetermined <br />Sucde Pending <br />260,. INJURY AT WORK <br />261. PLACE QF U �/,1! _h �I .farm. street facbry <br />269. LOCATNNJ STREET OR R.F.D. NO. CITY OR TOWN STATE <br />H0,mcde Investigation <br />Yes ❑ No ❑ <br />wnw �nR�ng <br />. DATE OF DEASTH /Ate.. y. Yc/ 28a. DATE SIGNED (Ma. Day. Yr) 28b. TIME OF DEATH <br />a ^� = <br />DEAD IHO fl <br />DA'T NED(AteDRY Yrl .TIME OF DEATH a� < 28c. PRONOUNCED DEAD (Ate.. DRY. Yrl 28d. PRONOUNCED <br />/E /) <br />M <br />8 <br />Lr 1 V <br />d. To am best of my knowledge. deatln occurred at the and place and due d N0, 28e. On tla basis examination t my opinion death occurred er <br />the <br />a due causelsl, <br />ctltteelsl stead. a the Ume. dots and pace and sue b the wuse((sl stand. <br />and Title Ire and Tidal Ili <br />SE CONTRIBUTE HE DEATH. a HAS ORGAN OR TISSUE DONATION� rB-E-ErN� CONSIDERED? WAS CONSENT GRANTED? <br />, <br />�[iO- <br />�31� <br />❑ YES ❑ NO IX I UNKNOWN ❑ VES /L_T�N,gr YES <br />NAME AND ADDRESS OF CERTIFIER ((PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI IType a Printl <br />Stephen E. Budd MD 3016 W Faidley,igrand Island Nebraska 68803 <br />320,. REGISTRAR 32b. DATE FILED BY REGISTRAR (&b.. Day Yi/ *& j 1 <br />FEB 2 6 1997 <br />