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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN_S_ERVICES SYSTEA 4 R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rfi6d `-FIE *77`H . THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_ *_IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE FEB l 2 2001 2 0 0 312) 304 ASSISTANT STI(TE bisvum LINCOLN, NEBRASKA HEALTH AND HUMAN_ SERVICES_SYSTE1W STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE1M_YICE$F&k&Cd;D SU4,R)RT VITAL STATISTICS _�{'[ .L 01007 CERTIFICATE OF DEATH _ - 1J 1. DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Month. Day. Year) Betty Jane Vavak Female= February 2. 2001 4. CITY AND STATE OF BIRTH ld not h USA.. name country/ 5a. AGE -Last BirthdayUNDER l YEAR UNDER 1 DAY 6. DATE OF BIRTH lMprklix Day Year) Pender, Nebraska Vrsl 76 Sb MOS i DAYS Sc. HOURS MINI January 30 • 1925 7. SOCIAL SECURTIY NUMBER Its PLACE OF DEATH 507-22-2785 HOSPITAL ❑ Inpatient OTHER a Nursing Home Suicide Pending Homicide Investigation ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name l/Inot mshfulicn give street and number) Park Place Nursing Care Center ❑ DOA ❑ Other(Specdyt 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS COUNTY OF DEATH Grand Island Yea D No ❑ Igo Hall ga. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER llncludirg lip Code) go INSIDE CITY LIMITS Nebraska Hall Grand Island 124 S. Kimball- 68801 Yes ® No ❑ 10 RACE - (e.g., While. Black, American Indian 11. ANCESTRY fog, Nation. Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /d wrfa give maiden name) etc I SSpecify) White Spec fyl American NEVER DIVORCED Stanley Vavak 31 NAME AND ADDRESS 061 CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type or nt) William L. Fowles M -D. 908 N- Howard, Grand Island NE, 68803 MAR I 32b. DATE FILED BY rCoL4JjiAR0tA%D82Yg0I a USUAL OCCUPATION /Give kind of week done during most tab KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary Ondary 10 -121 College (1 4 or 5 -I ` of wee even d retired) �i 'rarian Grand Island City Library . FATHER -NAME FIRST MIDDLE LAST I MOTHER FIRST MIDDLE MAIDEN SURNAME �17 Burdette Clifford Smith Mary Jane Sommers . WAS DECEASED EVER IN U.S. ARMED FORCES? 79a INFORMANT NAME (Yes (1 6 unk.) fit yes. give war and dates of services) Stanley Vavak 19b INFLLOVVRMANT MAILING ADDRESS (STREET OR R F NO. CITY OR TOWN. STATE. ZIP) 24 South Kimball Grand Island. NE 68801 20 EM LMER - SIGNATURE 8 LICENSE NO 13 21 a. METHOD OF DISPOSITION 21 b. DATE 21c. CEMETERY OR CREMATORY NAME 0 ❑ Burial r ,._,,, Feb 6 2001 Centrai Nebraska Crematior 22a. FUNERAL KOME -NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes ® Cremation ❑ Ddnal,or Gibbon, NE 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 1123 West Second Grand Island NE. 68801 23 IMMEDIATE C/%tl E (ENTER ONLY ONE CAUSE PER LINE FOR ial (b I. AND loll 1 Interval between o and deam PART ' idl I e DUE TO. OR AS A CONS NCE IIQI- Interval between onset and death I �/ (b) : lJ� C. v A j- DUE TO. OR AS A CONSEQUENCE OF /mgvan oelween onsen am main 1 11 fc) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONET 11 (Ages 10 -541 Yes No Yes No Yes No 26a. 26b. DATE OF INJURY (Ma.. Day. Yc/ 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined M Suicide Pending Homicide Investigation 26e. INJURY AT WORK Ves ❑ No 261. PLACE OF INJURY -e, Fame. farm. street. factory office buikfing. etc. /Specify/ 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATH (MO.. Day. Yr) -Yn Z, 200 a> 28a. DATE SIGNED /Mo.. Day. Yr) 28b. TIME OF DEATH M g dam€ i tj .2 Yc � ° a 27b. DATE�BIQ ^D /Mo.. Day. Y�cl7Q,�� 4- 27c. TIME OF DEATH 28c PRONOUNCED DEAD /Ma_ Day, YrI 28d. PRONOUNCED DEAD (Hour) M 27d. To M best 01 my :71 .bath oc cselsl stated. ,red at tlMe a dace an0 due to the 280. On the basis of examination an0,a investigation, in my opinion death occuned at the time, date and place and due to the causels) slated. (Signature and Tito Ul " S nature and Title 29. DID TOBACCO USE CONTRIBUTE T THE D ? 30.a HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? 30.D WAS CONSENT GRANTED? ❑ YES -NO ❑ UNKNOWN ❑ YES O ❑ YES NO 31 NAME AND ADDRESS 061 CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type or nt) William L. Fowles M -D. 908 N- Howard, Grand Island NE, 68803 32a. REGISTRAR 32b. DATE FILED BY rCoL4JjiAR0tA%D82Yg0I