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<br />WHEN TIWS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND WAGN SERVICES
<br />SYSTE14 IT CERTF ES T14E BELOW TO BE A TRUE COPY OF THE ORIGINAL RED V RL-WITM
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST0��M#" ,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />COOMW
<br />JAN 16 2002 200313846 A *TA1 ,
<br />LINCOLN, NEBRASKA HEALTH AND HEl_b1AIfF- SERVICES -�1f$
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SgjVICES -F iAF A b S T
<br />VITAL STATISTICS 14983
<br />CERTIFICATE OF DEATH =- --
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2, SEX
<br />i J
<br />Emanuel John Henry Suhr
<br />Male -
<br />December 29, 2001
<br />�6,
<br />4. CITY AND STATE OF BIRTH /M rtdn USA.. name country/
<br />5a. AGE - Last Birthday
<br />r7
<br />UNDER I DAV
<br />DATE OF BIRTH (Month. Day Year;
<br />O
<br />(Vrs.l Sb.
<br />\
<br />Girl
<br />° __4
<br />rn
<br />Aril 13 1916
<br />C D
<br />:
<br />N
<br />HOSPITAL: ❑ Inpatient OTHER. El Nursing Home
<br />—
<br />❑ ER Outpatient ❑ Residence
<br />\
<br />�7
<br />❑ DOA ® Other,SpecN) Skilled Care
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />O
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes P9 No ❑
<br />°
<br />�
<br />9b.: OUN TY 9c CI IY. TOWN OR LOCAI ION
<br />oWit`
<br />Nebraska
<br />N
<br />o
<br />CL
<br />o
<br />12 MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /N wde give rn -1 ,name)
<br />oT'
<br />.vy-
<br />❑ NEVER DIVORCED
<br />MARRIED
<br />W
<br />14a USUAL OCCUPATION /Give kind or work done during most 141,
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpecnly only highest grade ::omoletedi
<br />of working life. even it retired/
<br />Engineer
<br />Construction
<br />EI s oGra Colege
<br />% , ..
<br />m
<br />�,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />=0
<br />Minnie NMI NuyL
<br />18 WAS DECEASED
<br />Yes
<br />EVER IN U.S. ARMED FORCES? t�7f�7
<br />II
<br />19a INFORMANT - NAME
<br />no or unk.)
<br />Yes
<br />(If yes. give war and dates of services) yYYY
<br />03103/43 - 02/23/46
<br />r- D
<br />C
<br />w
<br />20 EMBALMER - SIGNATURE 8 LICENSE �!Q +i 9 / 1
<br />21 a. METHOD OF DISPOSITION r21D DATE 21c CEMETERY OR CREMATORY NAME
<br />-I�t�1Tu. `_ 7
<br />® Burial ❑Removal Jan 3, 2002 Westlawn Memorial Park Cem(
<br />21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />121d
<br />22a FUNERAL HO M - NA
<br />00
<br />❑ Cremation ❑ Donal-or
<br />°
<br />_
<br />22b FUNERAL HOME ADDRESS ISTREET OR RE . NO CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front Street, Grand Island, Nebraska 68803
<br />IMMEDIATE CAUSE Interval 1,etween onset iho neat,
<br />(ENTER ONLY ONE CAUSE PER LIN FOR a, IN AN K(CL4,4
<br />a A A
<br />OUE TO, OR AS A CONS UENCE OF Interval etween onset ann death
<br />(b)
<br />D
<br />i
<br />(c)
<br />s
<br />III IF FEMALE. WAS THERE A 221�'AUTOPSY
<br />CD
<br />cn
<br />CD
<br />C7�
<br />EXAMINER OR CORONER'
<br />(Ages 10 -54) Yes No
<br />Ulf
<br />,.,.
<br />26a.
<br />26b. DATE OF INJURY (MO. Day Y[/
<br />26c. HOUR OF INJURY
<br />261. DESCRIBE HOW INJURY OCCURRED
<br />Accident [-I Undetermined
<br />O
<br />M
<br />❑ Suicide 0 Pending
<br />WHEN TIWS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND WAGN SERVICES
<br />SYSTE14 IT CERTF ES T14E BELOW TO BE A TRUE COPY OF THE ORIGINAL RED V RL-WITM
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST0��M#" ,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />COOMW
<br />JAN 16 2002 200313846 A *TA1 ,
<br />LINCOLN, NEBRASKA HEALTH AND HEl_b1AIfF- SERVICES -�1f$
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SgjVICES -F iAF A b S T
<br />VITAL STATISTICS 14983
<br />CERTIFICATE OF DEATH =- --
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2, SEX
<br />D OF DEATH /Month. Day. Year)
<br />Emanuel John Henry Suhr
<br />Male -
<br />December 29, 2001
<br />�6,
<br />4. CITY AND STATE OF BIRTH /M rtdn USA.. name country/
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAV
<br />DATE OF BIRTH (Month. Day Year;
<br />(Vrs.l Sb.
<br />MOS. I DAYS
<br />Sc. HOURS ' MINS.
<br />Beaver Crossing, Nebr ka
<br />Aril 13 1916
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -18 -7723
<br />HOSPITAL: ❑ Inpatient OTHER. El Nursing Home
<br />—
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (It not msprution. give street and numbers
<br />St. Francis Skilled Care Unit
<br />❑ DOA ® Other,SpecN) Skilled Care
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes P9 No ❑
<br />Hall Count
<br />0. RESIDENCE -STATE
<br />9b.: OUN TY 9c CI IY. TOWN OR LOCAI ION
<br />9tl STREET AND NUMBER /Including Zip Code) +e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall Grand Island
<br />407 Lake St., 68801 Yes ® No ❑
<br />10 RACE - (e.g.. White. Black. American Indian
<br />11. ANCESTRY (e. g.. Italian. Mexican. German, etc)
<br />12 MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /N wde give rn -1 ,name)
<br />etc) (Sceaty) White
<br />White
<br />(Spec ty) Gerinan
<br />I l7G
<br />❑ NEVER DIVORCED
<br />MARRIED
<br />Betty J Scarborough
<br />14a USUAL OCCUPATION /Give kind or work done during most 141,
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpecnly only highest grade ::omoletedi
<br />of working life. even it retired/
<br />Engineer
<br />Construction
<br />EI s oGra Colege
<br />% , ..
<br />16 FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Frank NMI Suhr I
<br />Minnie NMI NuyL
<br />18 WAS DECEASED
<br />Yes
<br />EVER IN U.S. ARMED FORCES? t�7f�7
<br />II
<br />19a INFORMANT - NAME
<br />no or unk.)
<br />Yes
<br />(If yes. give war and dates of services) yYYY
<br />03103/43 - 02/23/46
<br />Betty J • Suhr
<br />19b INFORMANT MAILING ADDRESS o TREET OR R F D NO. CITY OR TOWN. STATE. ZIPI
<br />407 Lake Street, Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE �!Q +i 9 / 1
<br />21 a. METHOD OF DISPOSITION r21D DATE 21c CEMETERY OR CREMATORY NAME
<br />-I�t�1Tu. `_ 7
<br />® Burial ❑Removal Jan 3, 2002 Westlawn Memorial Park Cem(
<br />21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />121d
<br />22a FUNERAL HO M - NA
<br />1
<br />❑ Cremation ❑ Donal-or
<br />Island Nebraska
<br />_
<br />22b FUNERAL HOME ADDRESS ISTREET OR RE . NO CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front Street, Grand Island, Nebraska 68803
<br />IMMEDIATE CAUSE Interval 1,etween onset iho neat,
<br />(ENTER ONLY ONE CAUSE PER LIN FOR a, IN AN K(CL4,4
<br />a A A
<br />OUE TO, OR AS A CONS UENCE OF Interval etween onset ann death
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />i
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 221�'AUTOPSY
<br />2 WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />(Ages 10 -54) Yes No
<br />yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (MO. Day Y[/
<br />26c. HOUR OF INJURY
<br />261. DESCRIBE HOW INJURY OCCURRED
<br />Accident [-I Undetermined
<br />M
<br />❑ Suicide 0 Pending
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJURY - At honre, farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />Yes No ❑
<br />o8ice budding etc. lSpeci/y/
<br />2Ta. DATE OF DEATH /Ma. Day Yr.)
<br />28a DATE SIGNED (Mo. Day Yr I
<br />28b. TIME OF DEATH
<br />M
<br />ti
<br />2k b. DATE SIGNED (Mo. Day Yr.,I
<br />Oc TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMO_ Day. Yr)
<br />28d. PRONOUNCED DEAD IHOU ;
<br />0
<br />9 -� --
<br />M
<br />g z� -
<br />_-
<br />M
<br />� To the best of m nowledge. dea cut retl at the a e a dace a due to the
<br />28e. On the basis of examination and or investigation, in my opnion death occurred at
<br />° a° °
<br />cause(s) stated. `N
<br />° =
<br />the time, date and place and due to the cause(s) stated.
<br />`
<br />(S_ nature ant Title ► " , ► `T ` v
<br />( nature and Title
<br />2�,2ID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />_HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3b
<br />WAS CONSENT GRANTED'
<br />❑ YES 'V�r NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) hype or Pimp
<br />jQhn j, Cannella Mp, 729 N. Custer t Grand Island Nebraska 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day Yr.)
<br />ft
<br />JAN 15 2002
<br />I&
<br />�T
<br />
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