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<br />WHEN TH S COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO$W 1QNNfILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC-, _- _ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />he
<br />DATE OF ISSUANCE �-
<br />200315881 rl ANLEY S C061'Et
<br />12/1/2003 ASSZSTE�_ _GJS,R1R
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S$RVi4lt$L�PORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH 03 13319
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monts. Day. Year/
<br />Elmer Lee McNish
<br />Male
<br />I November 17, 2003
<br />4. CITY AND STATE OF BIRTH fl/not in U.S.A.. name country/
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH fMOnth. Day. Year)
<br />Topeka, Kansas
<br />(Yrs.) 73 51.
<br />MOS. I DAYS
<br />--
<br />April 18, 1930
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />509 -26 -8390
<br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />ZA
<br />St. Francis Hospital
<br />❑ DOA ❑ Other(Specdvl
<br />Sc. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />r
<br />Yea ® No ❑
<br />--
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />-�
<br />=
<br />CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />7INSIDE
<br />1611 W. John St.
<br />a © No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />T
<br />13. NAME OF SPOUSE f// wife. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />German - Scottish
<br />s:
<br />Alta B. King
<br />14a. USUAL OCCUPATION (Give Rindof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />w
<br />O>-
<br />° a
<br />- Elementaryorr2hdary 10 -12) College 11 -4 or 5�i
<br />j, LL
<br />1 & FATHER -NAME FIRST MIDDLE LAST 1
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William McNish
<br />n
<br />6:j
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (8 yes, give war and dates of services)
<br />1
<br />\�ti
<br />Alta B. McNish
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1611 W. John St. Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />• #�3O?�
<br />® Burial ❑ Removal
<br />Nov. 20, 2003 T
<br />estlawn Memorial Park
<br />22a. FUNERAL HO -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes F.H_
<br />❑cramalion E] Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second St. Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUL (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND )c)) Interval be onset and death
<br />PART j[.`�^- \ I
<br />I
<br />lal I
<br />j
<br />DUE TO, OR AS A CONSEQUENCE OF - Interval between onset and death
<br />I
<br />(b) I
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />(c) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No D
<br />Yes 0 No
<br />Yes No
<br />C
<br />?vim
<br />26c. HOUR OF INJURY
<br />-T' =c
<br />-Tj(/
<br />7 Accident F] Undetermined
<br />k
<br />Suicide Pending
<br />�1
<br />r
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />c3
<br />C-3
<br />N 2
<br />-
<br />27a. DATE OFF DEAT /Mo.. Day. r.J
<br />28a. DATE SIGNED /Mo.. Day. Yrl
<br />28b. TIME OF DEATH
<br />M
<br />iJ -`
<br />D
<br />Sa
<br />�
<br />27b. DATE SIG ED /MO.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fMo.. Day, Yrl '
<br />28d. PRONOUNCED DEAD (hour)
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<br />1747 M
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<br />27d. To the best of MV knowledge. death occurred at the , date and place and due to the
<br />2Be. On the basis of examination and,or investigation, in my opinion death occurred at
<br />causes) stated.
<br />°
<br />the time, date and place and due to the cause(s) stated.
<br />�7
<br />ISi nature and Title( ji�
<br />(Y)
<br />CD
<br />HAS ORGAN OR TISSUE DONATIO N CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />E] YES N N. ❑ UNKNOWN
<br />BEEN
<br />1:1 YES "I I NO
<br />❑ YES /�Lxj NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) fTypeor Prinfl
<br />Gordon Hrnicek, M.D. 729 lorth Custear i4rand Island, Nebraska 68801
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR D v Yr)
<br />CD
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<br />I
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<br />U
<br />WHEN TH S COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO$W 1QNNfILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC-, _- _ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />he
<br />DATE OF ISSUANCE �-
<br />200315881 rl ANLEY S C061'Et
<br />12/1/2003 ASSZSTE�_ _GJS,R1R
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S$RVi4lt$L�PORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH 03 13319
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monts. Day. Year/
<br />Elmer Lee McNish
<br />Male
<br />I November 17, 2003
<br />4. CITY AND STATE OF BIRTH fl/not in U.S.A.. name country/
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH fMOnth. Day. Year)
<br />Topeka, Kansas
<br />(Yrs.) 73 51.
<br />MOS. I DAYS
<br />Sc. HOURS MINS.
<br />April 18, 1930
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />509 -26 -8390
<br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /lino/ insNfution, give streetand number)
<br />St. Francis Hospital
<br />❑ DOA ❑ Other(Specdvl
<br />Sc. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yea ® No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER flncluding Zip Cadet
<br />CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />7INSIDE
<br />1611 W. John St.
<br />a © 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 f// wife. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />German - Scottish
<br />NEVER DIVORCED
<br />R,
<br />Alta B. King
<br />14a. USUAL OCCUPATION (Give Rindof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />1 15. EDUCATION (Specify only highest grade completed(
<br />of working life, even itrefiredl
<br />Bus Driver
<br />Transportation
<br />- Elementaryorr2hdary 10 -12) College 11 -4 or 5�i
<br />j, LL
<br />1 & FATHER -NAME FIRST MIDDLE LAST 1
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William McNish
<br />Della Draulents
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? -
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (8 yes, give war and dates of services)
<br />1
<br />No
<br />Alta B. McNish
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1611 W. John St. Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />• #�3O?�
<br />® Burial ❑ Removal
<br />Nov. 20, 2003 T
<br />estlawn Memorial Park
<br />22a. FUNERAL HO -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes F.H_
<br />❑cramalion E] Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second St. Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUL (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND )c)) Interval be onset and death
<br />PART j[.`�^- \ I
<br />I
<br />lal I
<br />j
<br />DUE TO, OR AS A CONSEQUENCE OF - Interval between onset and death
<br />I
<br />(b) I
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />(c) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No D
<br />Yes 0 No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY fMo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d., DESCRIBE HOW INJURY OCCURRED
<br />7 Accident F] Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. oPLAe b O.F INNJeUtRY - At ho farm, street. factory
<br />8ii
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑. No ❑
<br />-
<br />27a. DATE OFF DEAT /Mo.. Day. r.J
<br />28a. DATE SIGNED /Mo.. Day. Yrl
<br />28b. TIME OF DEATH
<br />G =t
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<br />M
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<br />27b. DATE SIG ED /MO.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fMo.. Day, Yrl '
<br />28d. PRONOUNCED DEAD (hour)
<br />r
<br />�1
<br />/
<br />1747 M
<br />��o
<br />M
<br />$
<br />S .1 Sz
<br />,9 °
<br />27d. To the best of MV knowledge. death occurred at the , date and place and due to the
<br />2Be. On the basis of examination and,or investigation, in my opinion death occurred at
<br />causes) stated.
<br />°
<br />the time, date and place and due to the cause(s) stated.
<br />ISi nature and Title( ji�
<br />- (Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.
<br />HAS ORGAN OR TISSUE DONATIO N CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />E] YES N N. ❑ UNKNOWN
<br />BEEN
<br />1:1 YES "I I NO
<br />❑ YES /�Lxj NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) fTypeor Prinfl
<br />Gordon Hrnicek, M.D. 729 lorth Custear i4rand Island, Nebraska 68801
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR D v Yr)
<br />NOV 003
<br />V
<br />
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