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<br />200314078
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DFATFI
<br />1 I ?ECF.DENT -NAME FIRST
<br />MIUDI F LAST
<br />2 SF%
<br />I DAIL OF DEATH 4f v r, 7 -1n 1 T•1
<br />Rita Marie
<br />Day
<br />Female_
<br />October 24, 2002
<br />4 r;ILr ANO STATE OF BIRTH / / /nnl in ( /$A. name cpunl
<br />- - -- - - --
<br />yl 5a AGE last Bilth[tay UN 1 YEAH UNUER t DAY 6 UATF OF RIR I11 .41,•nryr /, n trar�
<br />Parsons, Kansas
<br />IV 1 5h MOS DAYti 5 IJOURS MINS I
<br />81 _L L February 17, 1921
<br />- - - -- -
<br />i 7 S(N IA[ SECURITY NUMBF'R
<br />506 -18 -6459
<br />6a PI ACE OF OFA IhI
<br />HOSPITAL LA 111-re" OTHER [� Nll,s �,ll H- 11.11,
<br />_
<br />ab Tn, .II ITV rJame tit nnl,ncl,lulrpn. p,ue alreRl andnn,rbprl FR Oinpalienl ( -, ReSde ";••
<br />St. Francis Medical Center �l " "" �� ! "'"" `''' ^ - - - -- --
<br />-
<br />_ u - --
<br />6c ! -IIY tDWN OR LUCATION C\F DEA IM
<br />- -- - - - -- — - _ - -- -
<br />6tl INSIDE (:ITV lIMI1S P> ['OUNTV OF DFA I11
<br />Grand Island
<br />Yes [ IJp ❑ Hall
<br />-- - _
<br />9a R1 "tiIDFNCF. STAFF 9h COUNTY
<br />91 CIrY. TOWNORLOCAIIQN 9d STREET ANDNUMBF.R Ilnr(ud�ng Z,p Ctvfe+! r+ r1. :i!F -
<br />Nebraska Hall
<br />Grand Island 3119 W. Faidley Ave. Yezj
<br />10 F1AF;E leg. Wfule Blafk Ainerranlnr1 a, II ANCES
<br />_
<br />TRY Ieq Italian. Mean. ierman. etc.) 12 MARRIED r " -'j WIDOWED II NAME OF SPOUSE 01-4, o,v. a / , , +r
<br />elr'ISner, tyl ISpecAyl NEVER Lf DIVORCED_
<br />White French_ MAFIRIED Anthony Day
<br />14a USUALOCCUPATION iGrveh,ndnfwx,rkdnneduring,nnsJ
<br />o wprAmg Le. even r/rehretl)
<br />_ Secretary
<br />141, KIND OF BUSINESS INDUSTRY EDUCATION (Speoly o,lly highest grade[ompinledl
<br />1_15
<br />Elemnnla,y or $erondary Ill 121 College it I
<br />& School Offices 2
<br />16 FATHER NAME FIRST
<br />__
<br />MIDDLE LAST t 7 MOTHER FIRST MIUf11.F MAIDEN SURNAME
<br />Louis J.
<br />Raymond Loretta M. Martin
<br />18 WAS DECEASED EVER IN US ARMED FORCES?
<br />19, INFORMANT. NAME _
<br />f Yes nn. or unk.I 'If yes give war and dales of services)
<br />28b TIMF OF DEATH
<br />No I -- - - - - --
<br />Kit Noel
<br />19h INFORMANT MAILING ADDRESS
<br />IS TREET OR R D NO CITY OR TOWN ST ATF ZIP(
<br />12928 Hawkins Dr., San Ramon, California 94583
<br />27b DATE SIGNED /Mn Day Yrl
<br />20 EMBALMER - SIGNATUREBLICENSE NO
<br />21a METHOD OF DISPOS1IION 21 b. DATE 21c CEAIF TEHY OR CHRdn InRr NAME
<br />28tl PRONOl1NCFD DEAD
<br />Not Embalmed
<br />F-1Bunal ❑Rem[r.al ct. 25, 2002 Westlawn Crematory
<br />10:35 pm M
<br />22. FUNERALHOME NAME
<br />-_
<br />2111 CFMFi FRVORr�HFMAIOAH IOCATION (.ITI ,rR tOWN ::le
<br />f:
<br />Livingston - Sondermann
<br />F.H. ©Cremal,on ❑ ° ° ^ ° °° Grand Island, Nebraska
<br />27tl To the bps) of my knowledge death oc rred al the fi ale and place and due to the
<br />1 / cause's' stated
<br />�C f
<br />22b Fl1NERAl. HOME ADDRESS (STREET OR R F.O.
<br />NO CITY OR TOWN S7 ATI ?. ZIP)
<br />°
<br />r�
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />ISI nature and Title -� -
<br />IMMEDIATE CAUSE
<br />PART
<br />�- -_. -- -------- - - - - -- ----- - - - - -- -- -- - - - - --
<br />IENTEH ONLY ONE CAUSE PER t INE FOR la1 Ihl. AND Irll � Inln +vat hetwoen u,s,,
<br />/ I �
<br />29 DID TOBACCO USE 0ONTRIBUTTlb THE MWT.7
<br />3o a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />t23
<br />DUE TO. OR ASP CONS�EO�UiENCE OF
<br />,- YES NO
<br />YES (�/ /NO
<br />31 NAME AND ADD WS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATIORNEYI /Type or P
<br />jil QQ Alp Grand gland, N-E- __S2$80
<br />32a R2 is R
<br />. 32b DATE FILED BY REGISTRAR JMo Day Yrl
<br />DUF TO, OR AS A CONSEQUENCE OF
<br />Ime, v, I between n •
<br />OTHER SIGNIFICANT CONDyT1ON5 Cmdihons conlrihuling to the death but not related PART
<br />111 IF FEMALE. WAS THERE A
<br />1y4 Al11OPS
<br />N!A$ EASE HEFEHRE t , I fTF �
<br />PART PREGNANCY
<br />1N THE PAST J MONTHSn
<br />F%AtA1NFR OR COH—P "
<br />—
<br />(Ages 10 541 Yes No
<br />I
<br />I
<br />Yes No
<br />y Yes
<br />26a
<br />26b DATE. OF INJURY (MIT, . Day Yc)
<br />26c HOUR OF INJURY
<br />_NO
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Arcidenf Undetermined
<br />-
<br />M
<br />l So¢Ide Pendmq
<br />26e INJURY AT WORK
<br />26f PLACE OF INJUFTY - Al home, farm. street. factory
<br />o ice building. etc /Spec,tyl
<br />26g LOCATION STREET OR R F.D. NO CI1 Y OR TOWN
<br />Homicide Inveskgation
<br />Ves ❑ No ❑
<br />27a DATE OF DEATH JW Day Yrl
<br />28n DATE SIGNED iAlo Dav yr 1
<br />28b TIMF OF DEATH
<br />_
<br />'
<br />- rOctober 24, 2002
<br />a
<br />27b DATE SIGNED /Mn Day Yrl
<br />27c TIME OF DEATH
<br />2Bc PRONOUNCED DEAD ;Mn Day Y, I —
<br />28tl PRONOl1NCFD DEAD
<br />F"
<br />rOctober 25, 2002
<br />10:35 pm M
<br />_
<br />f:
<br />1.
<br />27tl To the bps) of my knowledge death oc rred al the fi ale and place and due to the
<br />1 / cause's' stated
<br />�C f
<br />26e. On the bass of ezarmnanon and or invesugauon, m my op�mm� dean, me urrad al
<br />the ume, date and place and due to the causelsl stated
<br />4
<br />°
<br />r�
<br />ISI nature and Title -� -
<br />, (Signature and Tdlel ►
<br />29 DID TOBACCO USE 0ONTRIBUTTlb THE MWT.7
<br />3o a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />3 GRANTED',
<br />VES �O UNKNOWN
<br />,- YES NO
<br />YES (�/ /NO
<br />31 NAME AND ADD WS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATIORNEYI /Type or P
<br />jil QQ Alp Grand gland, N-E- __S2$80
<br />32a R2 is R
<br />. 32b DATE FILED BY REGISTRAR JMo Day Yrl
<br />FOR VITAL STA- 1ISTICS USE ONLY
<br />Place....................... A..- .......................... B ..................... ........... C ................................ D ............................... .E ................................ Part II ................. ..... TMV.,...... .
<br />NSC . ............................... .........Census Tram No
<br />Work................................................................................................................................................................................................................... ............................... .
<br />UC ........................................................................................................................................................................................................................... ...............................
<br />Reject.................................................................................................................................................................................................. .............................. .. ..............
<br />4 P lnled with soy Ink on recycled Papa,
<br />hereby certify this to he a true and correct copy of the original
<br />111e d V"ith t' e State of iNu- braska
<br />[xnnea��; :, TERRY! . LOSCHEN ,>r
<br />MY COMMISSION EXPIRES
<br />my presen day of >ak:s� May 2, 2006
<br />ry Pu'� i i c
<br />
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