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F- -
<br />2. SEX
<br />3. DATE OF DEATH on .Day. I
<br />George Woodrow Codner
<br />Male
<br />December 12, 2002
<br />4. CITY AND STATE OF BIRTH fhnot in U.S.A.. name couney/
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16, DATE OF BIRTH (MOndt. Day. Year)
<br />Sb MOS DAYS
<br />E
<br />Rural Gibbon, Nebraska
<br />(Y,5) 83
<br />Jul 27, 1919
<br />7. SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />553 -34 -5250
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient L. i Residence
<br />fib. FACILITY - Name fan N,nslWhon, give sheer and number)
<br />13141 S. Bluff Ctr. Rd .
<br />❑ DOA ❑ Other (Specdyl
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8a INSIDE CITY LIMITS'
<br />ae!' COUNTY OF DEATH -
<br />Wood River
<br />Yes ❑ No ®
<br />Hall
<br />ga RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Including Z0 "83
<br />9e. INSIDE CITY LIMITS
<br />o
<br />Hall
<br />Wood River
<br />13141 S. Bluff Ctr. Rd.
<br />Yee ❑ No
<br />m
<br />m
<br />t2. © MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fly wife. give maiden name)
<br />��`.
<br />o
<br />F-r•z
<br />=
<br />cv
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />141, KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade eorpMbd(
<br />of waking life. even M refired)
<br />Farmer /Cattle Feeder
<br />Agriculture/Livestock
<br />Hemeraary, or Sac (4121 Cdlsge 41.441 VI
<br />10th Gra�e
<br />C-3
<br />CD o
<br />CAD
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />tga. INFORMANT - NAME
<br />(Yes. no or unk.) I is yes give war and dates of services)
<br />Yes 2 -19- 1941/12 -14 -1945
<br />Louise Codner
<br />"k
<br />18 200
<br />7:00 pm M
<br />O
<br />CL
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fMo. Day, YrI
<br />28d. PRONOUNCED DEAD /Four!
<br />4
<br />M
<br />Yl
<br />ecembe 12 200
<br />8:30 pm M
<br />Z'
<br />28e On the basis f e amination o investigation, in my opinion death occurred at
<br />cause(s) stated.
<br />°
<br />he ome, d, an plat o die c sl stated.
<br />,
<br />ISignature and Title) ►
<br />(Signature and Hall Co A t t
<br />2g. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />r
<br />❑ YES ❑ NO rL] UNKNOWN 'r
<br />❑ YES ® NO
<br />❑ YES ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type a Prin11
<br />(K, M
<br />32L REGISTRAR
<br />32D. DATE FILED BY REGISTRAR JW Day. Yia
<br />DEC 2 4 202
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<br />200315883
<br />WHEN TM COPY CARJtE3 THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEM, R CERTFES T1E BELOW TO BE A TRUE COPY OF THE ORIG MAL M
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM
<br />THE LEGAL DEPOSITORYFOR VITAL RECORDS . 1;7r _ -
<br />DATE OF ISSUANCE
<br />DEC 2 7 2002
<br />LINCOLN, NEBRASKA
<br />HEALTH AND
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFX
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />WR
<br />n/ 1 A4Go
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH on .Day. I
<br />George Woodrow Codner
<br />Male
<br />December 12, 2002
<br />4. CITY AND STATE OF BIRTH fhnot in U.S.A.. name couney/
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16, DATE OF BIRTH (MOndt. Day. Year)
<br />Sb MOS DAYS
<br />Sc IN
<br />HOURS' RAS
<br />Rural Gibbon, Nebraska
<br />(Y,5) 83
<br />Jul 27, 1919
<br />7. SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />553 -34 -5250
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient L. i Residence
<br />fib. FACILITY - Name fan N,nslWhon, give sheer and number)
<br />13141 S. Bluff Ctr. Rd .
<br />❑ DOA ❑ Other (Specdyl
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8a INSIDE CITY LIMITS'
<br />ae!' COUNTY OF DEATH -
<br />Wood River
<br />Yes ❑ No ®
<br />Hall
<br />ga RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Including Z0 "83
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Wood River
<br />13141 S. Bluff Ctr. Rd.
<br />Yee ❑ No
<br />10. RACE - (e.g., While. Black. American Indian
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etcl
<br />t2. © MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fly wife. give maiden name)
<br />etc.) ISpeclty)
<br />White
<br />ISpemfyl
<br />I American
<br />NEVER DIVORCED
<br />,
<br />Louise Cage
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />141, KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade eorpMbd(
<br />of waking life. even M refired)
<br />Farmer /Cattle Feeder
<br />Agriculture/Livestock
<br />Hemeraary, or Sac (4121 Cdlsge 41.441 VI
<br />10th Gra�e
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles Lester Codner
<br />Marie Schlake
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />tga. INFORMANT - NAME
<br />(Yes. no or unk.) I is yes give war and dates of services)
<br />Yes 2 -19- 1941/12 -14 -1945
<br />Louise Codner
<br />tyn. INYVHMANI MAIIINIi AUUHt,J 151 HttI UH H.F.U. NU.. LI I Y UH IUWN. J 1 A 1 t. LIY)
<br />13141 S. Bluff Ctr. Rd. Wood River. Nebraska 68883
<br />20. EM E - SIGNA b L NSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21 b. DATE
<br />21 c. CEMETERY OR CREMATORY NAME
<br />�-
<br />IN Burial ❑Removal
<br />Dec. 17 2002
<br />Shelton Cemetery
<br />22a. FUNERAL HOM AME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />f Livingston - Sondermann F.H.
<br />❑Cremation F] Donation
<br />Shelton Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. - IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND (q) Interval between onset and death
<br />,kAART
<br />'(al Cardiac arrest immediatp
<br />DUE TO, OR AS A CONSEQUENCE OF - I b limp! bowasrn onset and deaal
<br />I
<br />F
<br />DUE TO. OR AS A CONSEOUENCE OF: I Interval between onset and death
<br />I
<br />I
<br />Ic) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />u
<br />IN THE PAST 3 MONTHS?
<br />XEXAMINER OR CORONER?
<br />(Ages
<br />10 -541 Yes No n
<br />Yes n No
<br />Yes No
<br />26a.
<br />26b, DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F Undelermined
<br />M
<br />Suicide [:] Pending
<br />26e. INJURY AT WORK
<br />26f, PLACE OF_ INJURY - At home. farm, street. factory
<br />o ce building, etc At
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes No
<br />❑ ❑
<br />27a, DATE OF DEATH [Ai Day. Yr.)
<br />28a DATE SIGNED fMo. Day YU
<br />28b. TIME OF DEATH
<br />-k-
<br />"k
<br />18 200
<br />7:00 pm M
<br />O
<br />27b, DATE SIGNED fMo.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fMo. Day, YrI
<br />28d. PRONOUNCED DEAD /Four!
<br />4
<br />M
<br />32 zo s
<br />g 0
<br />° °
<br />ecembe 12 200
<br />8:30 pm M
<br />Xr 27d To the best of my knowledge. death occurred at tly time, date and place and due to the
<br />~ r
<br />-
<br />28e On the basis f e amination o investigation, in my opinion death occurred at
<br />cause(s) stated.
<br />°
<br />he ome, d, an plat o die c sl stated.
<br />,
<br />ISignature and Title) ►
<br />(Signature and Hall Co A t t
<br />2g. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />S CON ENT GRANTED?
<br />❑ YES ❑ NO rL] UNKNOWN 'r
<br />❑ YES ® NO
<br />❑ YES ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type a Prin11
<br />4erom E Janulewicz, Hall Cou ty Attorney, 231 S Locust, Grand Island,
<br />32L REGISTRAR
<br />32D. DATE FILED BY REGISTRAR JW Day. Yia
<br />DEC 2 4 202
<br />1 ! -
<br />
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