Laserfiche WebLink
EXHIBIT "A" <br />WHEN TM COPY CARRFES TW RAISED SEAL OF THE NEBRASKA HEALTH,AND HUMAN SERVICES <br />SYSTEM, R CERTIFES T1E BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTtOI - „ . <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />S COOPEF ' <br />10/23/2003 200314856 <br />AsslsrA� arA7 l i�TRAI -_ <br />LINCOLN, NEBRASKA HEALTH AND MAW M RZE ES sY M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES - iANrE- <br />VITAL STATISTICS _ �-3 11767 <br />rP.RTTFirATE OF DEATH - <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />Z SEX <br />3. DATE OF DEATH /Month. Day. Year) <br />Annetta Mae Fitzgerald <br />Female <br />October 9, 2003 <br />4. CITY AND STATE OF BIRTH lMnot in U.S.A. name country) <br />Sa. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Yea`( <br />Mi . Dnvs <br />5c. HOURS MINS. <br />Grand Island, Nebraska <br />(vim'' 6 8 sb. <br />July 26, 19 3 5 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />ITAL: ❑ Inpatient OTHER: ❑ Nursing Home <br />508-38-0824 <br />HOSP_ <br />❑ ER Outpatient Residence <br />(knot l ^slim^• 9" silreet and ^umber/ <br />r 8b. FACILITY -Name <br />2427 Commerce Ave. <br />h <br />❑ DOA ❑ Other (Specrlw <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CRY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />Be. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9Q STREET AND NUMBER /Including Zip Code) <br />9e. INSIDE CRY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2427 Commerce Ave. 68801 <br />Yes ® No ❑ <br />10. RACE - (e.g, While. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc( <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (d wile. give maiden name) <br />1.)"PIciy) White <br />(svedty) American <br />MEVER DIVORCED <br />.:.Denny Fitzgerald <br />14a. USUAL OCCUPATION !Give kind work done during mast 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elementary Or Secondary 10-121 College I7 -4 or 5 -1 <br />12 4 <br />of working life, every ifreo'red) <br />Homemaker <br />Own Home <br />16. FATHER -NAME FIRST MIDDLE LAST' t7. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />James Morris Mitchell <br />Roma Haack <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a INFORMANT -NAME <br />. (Yes. no. or unk.) (a yes. give war and dates of services) <br />No I <br />Denny i <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIP) <br />2427 Commerce Ave., Grand Island, Nebraska 68801 <br />2 MBALMER - A RE 8 LI NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21d, <br />CEMETERY OR CREMATORY NAME <br />#1071 <br />®..n. ❑Removal <br />octcber 13, 2003 Grand <br />Island City Cemetery <br />22arfONERAI HOME - NA <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />All Faiths Funeral Home' <br />El Cremation El Donation <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lab (b). AND (c)) I Interval between onset and death <br />I <br />PART •- _ I �• ^t` - <br />I A- <br />( al / <br />DUE TO, OR AS A CONS NCE OP I Interval between onset and death <br />-4�Nlra 1.LU,,,t C., �01/bt� -7 p, <br />(b) <br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death <br />I <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS . Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25. =REFERRED REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />PART PREGNANCY IN THE PAST 3 MONTHS? <br />II (Ages 10.541 - Yes No Yes No X Yes p No <br />26a. <br />28b. DATE Of INJURY /Ma. DaA�UR <br />OF INJURY <br />26Q DESCRIBE HOW IN,iJRY OCCURRED <br />Accident ❑ Undetermined <br />M <br />Suicide ❑ Pending <br />26e. INJURY AT WORK <br />261. PLACeCLQF IINgJU Y -,, hdc,. farm. street. factory <br />�sYY�I <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ NO ❑ <br />olh <br />27a. DATE OF DEATH (MO.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr) 28b. TIME OF DEATH <br />(a -I M <br />y 27b. DATE SIGNED (MO.. Day. Yr.) 27c. TIME OF DEATH i k y 28a PRONOUNCED DEAD /MO.. Day, Y0 28d. PRONOUNCED DEAD /hbml <br />7 :15 A. M s�� M <br />E <br />8 m ion death occurred at <br />~ n a investigation, s my opinion <br />°. 27d. To the best of my knowledge. death occurred at to time, dale and place and due to the 2Be. On tlK basis of exartice <br />a due to <br />causelsl stated. Pi K t1e tme, date and pace and due b the eausele) stated. <br />(/Aj�%�h _ �t <br />r ISi nature and Tice) ► V _'v r1 r`J (Si naure and TNe <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br />❑ YES ® NO ❑ UNKNOWN ❑ YES NO ❑ YES V%j NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type orPhnll <br />Anne K. Morse, M.D., 729 N. Custer Ave., Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (MO.. Day. Yr) <br />&"hA '_ . <br />OCT 2 2 2003 <br />