|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTIOIK WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -_
<br />DATE OF ISSUANCE
<br />ANLEY &- COflpEIR
<br />5/30/2003 200315522 ASSIST_AN]f SMTE RiGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S_E_RKICES FINANeEANI S1 iPPORT
<br />VITAL STATISTICS - - n (�
<br />riPR TTRTr A TR n1P TIP. A TT4 _ _ _ 1 ' � t 1 s ."1 .� 2
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2. SEX . _ - _-
<br />3. -DATE OF DEATH (Month. Day. Year)
<br />Ruby I.
<br />Walker
<br />Female
<br />May 25, 2003
<br />4. CITY AND STATE OF BIRTH /lint in U.S.A., name country)
<br />26h. DATE Of INJURY (MO.. Day, Yr./
<br />Sa. AGE - last Binhday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF BIRTH (Monts. Day. Year)
<br />Gibbon, Nebraska
<br />93(Yrs.)_83
<br />5b.MOS.I DAYS
<br />Sc. HOURS MINS.
<br />July 14, 1909
<br />7. SOCIAL SECURTIY NUMBER
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />Be. PLACE OF DEATH
<br />26a. DATE SIGNED (Mo.. Day. Yr)
<br />039-12-5213
<br />HOSPITAL: ❑ Inpatient OTHER n Nursing Home
<br />sw
<br />9
<br />sw 0
<br />° °c,�
<br />ci 8
<br />❑ ER
<br />Outpatient ❑ Residence
<br />8b. FACILITY - Name (g not inslitwion, give street and number)
<br />Good Samaritan Center
<br />28d. PRONOUNCED DEAD /Hour)
<br />M
<br />❑ DOA ❑ Other(Specdyl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Wood River
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a H S O GAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES LNO ❑ UNKNOWN ❑ YES NO
<br />I ❑
<br />I
<br />Hall
<br />Yes No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9e. CITY, TOWN OR LOCATION
<br />ga. STREET AND NUMBER (Including zip code)
<br />19387 West °Lepi
<br />Oe.IN51DE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Shelton
<br />Yea❑ No ]
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc)
<br />t2. ® MARRIED
<br />E] WIDOWED
<br />13. NAME OF SPOUSE (if wite. give maiden name/
<br />etc.) (Specify) White
<br />(Sp8Cityl
<br />American
<br />NEVER
<br />DIVORCED
<br />Donald Walker
<br />MARRIED
<br />14a. USUAL OCCUPATION /Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -12) College l typ or 5.1
<br />`t
<br />of waklag /ile, even d refkedl
<br />Teacher
<br />Education
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Irving nmi Weston
<br />Emma
<br />nmi Hall
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1Be. INFORMANT - NAME
<br />(Yes. no, or unk.) (If yes. give war and dales of services)
<br />No
<br />Donald Walker
<br />19b. INFUHMANI MAILINU AUUHtJJ Ial rtttr - n.r. u. nV., Vi i I Vn ivnn. --'. -,
<br />19343 West Lepin Road, Shelton, Nebraska 68876
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY - NAME
<br />( ) May 2 6 2 0 0 Central Nebraska
<br />not embalmed ❑ Burial ❑ Removal
<br />tion Services
<br />22a. FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Godberson Mortuary ®Cremation ❑Donation Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />719 Front Street, P.O. Box 10, Gibbon, Nebraska 68840
<br />23. II
<br />PART
<br />I
<br />(a)
<br />(b)
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PREGNANCY
<br />A
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />II /v OIL
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26h. DATE Of INJURY (MO.. Day, Yr./
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident r-1 Undetermined
<br />M
<br />Suicide n Pending
<br />Homicide Investigation
<br />26e. INJURY AT WORK
<br />Yes ❑ No ❑
<br />261. PSI ACE QF. IngNJBtRY �S r, farm, street, factory
<br />Ice bu kII
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />26a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />S
<br />S "Z� 43
<br />sw
<br />9
<br />sw 0
<br />° °c,�
<br />ci 8
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr)
<br />S LL.a 03;
<br />27c. TIME OF DEATH
<br />it S M
<br />r
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />28d. PRONOUNCED DEAD /Hour)
<br />M
<br />27d. To the best of my knowledge. death occurred me, dal nd p to the
<br />cause(s) stated.
<br />28e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s( stated.
<br />(Signature and Title
<br />Signature and Ttlle
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a H S O GAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES LNO ❑ UNKNOWN ❑ YES NO
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES y�l NO
<br />J1. NAMt ANU HUUf1CJJ Vr VCnrrrlCn lrnl�l•. Inn, VVnvn�n�rn•.avw�vn vv�n„n•v.•n•.,� i•rry •^••••v
<br />Gary Settje, M.D., STE 409, 2116 We5� Faidley Ave., Grand Island88NE
<br />ay. oarocT _i 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />South Half of the Southwest Quarter (S' /2SW %), Section Nineteen (19), Township Nine (9) North, Range Twelve (12), West of
<br />the 6'h P.M., Hall County, Nebraska
<br />Southeast Quarter (SE'/4), Section Nineteen (19), Township Nine (9) North, Range Twelve (12), West of the 6"' P.M., Hall County.
<br />Nahracka
<br />Prepared on November 21, 2003 (6:07pm) by Heinisch Law Office Telephone 4UZ- 15a -s1ZZ, tax 4UZ -10a -01/0
<br />
|