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Rev 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN =VX= FINANCE AND SUPPORT <br />VITAL ATIST" <br />CERTIFICATE OFF DEATH 200313091 <br />Z f <br />W <br />o { <br />W C <br />Q) <br />W <br />!� 1 <br />LL `. <br />O1 <br />Uj <br />Q j <br />Z L <br />t'7 <br />C7 <br />I DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (Aaarafl Day. t4aq _ <br />Dorothy Evelyn Frauen <br />Female <br />April 22, 2000 <br />a CITY AND STATE OF BIRTH rN not an US A name Cooney) <br />Sm. AGE - Last Blo day <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />a. DATE OF BIRTH AA1rQ DM. Yead <br />so MOS ' DAYS <br />S.. HOURS: PAINS <br />Cozad, Nebraska <br />(YrsJ 92 <br />February 10, 1908 <br />7 SOCIAL SECURTIY NUMBER <br />0a. PLACE OF DEATH <br />HOBPITAL ❑ InpalteM OTHER ® Nursing Hama <br />507 -36 -3152 <br />— -- <br />❑ ER Outpatient ❑ Reaidance <br />8b. FACILITY - Name (N nol'nsnfue'pn, give street and number) <br />Lakeview Rehab & Nursing Center <br />❑ DD" ❑ D"",ISPOCI,' - -- <br />Bc CRY TOWN OR LOCATION OF DEATH <br />ad. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yea ® No ❑ <br />Hall _ <br />9a RESIDENCE - STATE <br />COjNT Y <br />CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (kehdkgl/p CodN <br />ft WSIOE CITY LIA1: f 5 <br />Nebraska <br />'9b <br />19c <br />Grand Island <br />537 Ravenwood Ct. 68801 <br />mail -L] <br />_ <br />10 RACE - leg.. While. Black American Indian <br />le g . Italian. Mexican. Garman, etcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE IN era. pnw mom" daaw7 <br />etc I ISpeCItYl <br />White <br />pec"V <br />American <br />NEVER DIVORCED <br />Paul Frauen <br />t4 USUAL OCCUPATION iGrve kind of work dorw during m05r <br />1 /b. KIND OF BUSINESS INDUSTRY <br />10. EDUCATION <br />ISpecay dMY <br />EI�tBtWy a 9 ondar 10 -t2) Cda9a II A a 5 i <br />1[th (>rae <br />of working Ide, even d rented! <br />Secretary /Bookkee er <br />Oil Company <br />16 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAW <br />Morris Moeder <br />Mabel Adams <br />16 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />IYes. rw. or unk.l X yes. give war and dales W servicesl <br />No --- - - - - -- <br />Paul Frauen <br />t 9b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI <br />537 Ravenwood Ct., Grand Island, Nebraska 68801 <br />20. EMS ME - SIGNA 8 NO <br />n� WM71 <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />aBow ❑Removal <br />Apr. 25, 2000 <br />Grand Island City Cemeter <br />..- <br />22a FUNERAL HOMVME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin stop- Sondermann F.H. <br />❑ Cremamon ❑ Donation <br />Grand Island, Nebraska _ <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMME(DI CAUSE (ENTER ONLY ONE OUSE PER LINE Ib6 AND Itll f Mtw h onaM ano e.Mr <br />/ATE �FOR /IaL /rva�l <br />PART /gaes'aa^ <br />� �,�, /. /n/ <br />DUE TO, OR AS A CONSEQUENCE OF I alfwwll oaaaaa^ 0nm <br />I <br />I <br />(b) <br />DUE TO.OR AS A CONSEQUENCE OF ' atlervat' areal OW derail <br />I <br />Icl <br />OTHER SIGNIFICANT CONDITIONS - Conditions comilb ing to ate death bul not related PART III IF FEMALE WAS THERE A 24 . AUTOPSY N —WAS CASE REWIRED TO MEDICAL <br />PART PREGNANCY W THE PAST 3 MONTHS? IT <br />a <br />(Ages 10•541 Yes 11 No Y. No Yw r Np <br />26a 26b. DATE OF INJURY (MO.. Day. YrJ 26c. HOUR OF INJURY 28d, DESCRIBElIOW 9UURY <br />nAccid0M O Undetermined M <br />0 Suicide C:1 Pending 26e INJURY AT WORK 1 261 PPk.Ae E QF .UtepY -,�, term, skeet, lacbry 209. LOCATION STREET OR RF.D. NO. CITY OR TOWN STATE <br />Homicide Investigation Yes ❑ No ❑ �� <br />27a DATE OF DEATH (Mo.. Day Yr) 26s. DATE SIGNED (Aft. Day. YO 28Q TIME OF DEATH <br />k Aril 22,20+00 <br />a a _K__ <br />27b. GATE SIGNED (Ab.. Day Yr/ 27e. TIME OF DEATH k > 280. PRONOlX7CED DEAD ft. Oqt Yr./ 1St1 PNONOUNC�1 OE,W F14rf <br />April 24 2:50 M s i M <br />27d To dta best of my knowlillos. IDXM """ad at the None, and plate and due to the 28a. On f ball d 1aathitna n ani la InMaapaatan, in my 0/Illan dp01 abLSalaO a <br />J!tanelsl stated. 0 Q /. b 0w itme. Mite ant) place and dui b IM C&UMM M U& <br />OBACCO USE CONTR12kfIE T THE DEATH? U I 30.a HAS ORGAN OR TISSUE DO <br />❑ YES ❑ UNKNOWN 1— ❑ YES <br />: AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY) (T) <br />32a <br />FOR VITAL STATISTICS USE ONLY <br />Place.......................A ................................ B ................................ C ................................ D ................................ E ... <br />NSC................ . .......................................................... . ........... .............................................................................................. <br />Work.................................................................................................................................................... ............................... <br />UC ......................................................................................................................................................... ...........I.............I..... <br />Reject................................................................................................................................................. ............................... <br />Printed with WY Inds Von rscyelad ~116 <br />r'li` 1 (1 llti� = - rr <br />i. {iG a �r{;i: i'nG �orr,,,r� copy ill Ile Sri <br />a <br />1i( to 1 i <br />illeU 'r� +� p k„Grl✓ ��I r ,Llr�?,"Sa <br />S,Cljp {J ill ipj/ pp 0 I ) <br />11 YES /Irin NO <br />..............Part II .................. .... TMV ...._............. .. <br />..................... ............................... Census Tract No <br />...................... ............................... <br />TERRY L. LOSCHEN <br />MY COMMISSION EXPIRES <br />• M1OTAPY� <br />May 2, 2006 <br />