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<br />Rev 11197200512332
<br />
<br />.. DECEDENT. NA"'E
<br />
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALnt AND HUMAN SERVICES FlNANCB AND stJPPORt
<br />vttAL STA nsncs
<br />CERTIFICATE OF DBA 1H
<br />FIRST MIDOlE lAST 2. SEX ". ~TE OF I)EATlt _ o.r. Y'"
<br />
<br />Beatrice
<br />
<br />Lee
<br />
<br />Wiese
<br />So. AGE - lMl_v
<br />lV'll 68
<br />
<br />UNDER 1 YEAR
<br />~. MOS. DAYS
<br />
<br />Female
<br />UNDER . ~Y
<br />St. HOURS ' MlNS.
<br />,
<br />
<br />April 5, 2000
<br />I. DATE OF IIRTH ~ o.r V_I
<br />
<br />4. CITY AND STAre OF BIRTH ,.""'''' u.s.A.. no"",countryl
<br />
<br />lib. FACILITY. Nome
<br />
<br />(II IkJt IMtttutm. gIVe 5""' ~nd nu~
<br />
<br />llo. PlACE Of' DEATH
<br />~~ 0
<br />o
<br />o
<br />
<br />I~ OTHER:
<br />ER 0Ulpali0nI
<br />OOA
<br />
<br />January 20, 1932
<br />
<br />DNotIIIlo-
<br />g-
<br />O 0Ih0< ~
<br />
<br />Grand Island, Nebraska
<br />7. SOCiAl SECURTIY NUMBER
<br />
<br />.
<br />
<br />507-36-1900
<br />
<br />.
<br />
<br />2516 Pioneer Blvd.
<br />8c. CITy TOWN OR lOCATION Of' DEATH
<br />
<br />lid. INSIDE CITY liMITS
<br />
<br />Kensin
<br />
<br />
<br />1/nC/IJdIrI/Iz-.
<br />
<br />Nebraska
<br />10. Fl:ACE. (e.g" WNt.. Btack. "'mer~.n indian.
<br />....IISpoeilyl
<br />White
<br />
<br />
<br />Grand
<br />,.. ANCESTRY log.. ".Iion. Me,ie.n. G...........""'I
<br />IS....i1V1
<br />American
<br />
<br />Y. fi) No [}
<br />
<br />90. RESIDENCE. STATE
<br />
<br />Ci
<br />c:
<br />o
<br />o
<br />o
<br />~
<br />c:
<br />;;,
<br />o .
<br />o .
<br />..
<br />o .
<br />
<br />MIDDlE
<br />
<br />Retail
<br />lAST
<br />
<br />Jack Wiese
<br />n. EllUCATlON t
<br />~O/~to-l
<br />Ilth Grade
<br />UIllOlE
<br />
<br />0alI0v& 11-4 '" ~"
<br />
<br />
<br />... USUAL OCCUPATION IG.wkInllOl__I1IJrlng_
<br />at_inglilfl._K_
<br />Owner
<br />
<br />FIRST
<br />
<br />IWJl;N lIUIlNAllE
<br />
<br />Thelma
<br />
<br />Ball
<br />
<br />~
<br />E
<br />ctI
<br />)(
<br />Q)
<br />lil
<br />o
<br />t-'5
<br />Z Q)
<br />W E
<br />o g
<br />W(j
<br />Uiij
<br />W>.
<br />O.J;;.
<br />u.Q.
<br />O~
<br />W 3:
<br />~ :3
<br /><( ..
<br />Z.r
<br />M
<br />M
<br />
<br />'lib. INFORMANT
<br />
<br />MAilING ADDRESS
<br />
<br />Jack Wiese
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. Z1P)
<br />
<br />
<br />rand Island ~ebraska 68801
<br />210. METHOD OF DI T10N 21b. DATE
<br />
<br />gt/'-
<br />
<br />[XI 8,,",,1
<br />
<br />o Removal
<br />
<br />
<br />21C. CEMETEIWOR CAalATOAV . NAME
<br />
<br />Ceme t~_!::r
<br />STAH
<br />
<br />L1vin ston-Sondermann F .H. Oc.-m DDooaOOn
<br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO. CITY OR TOWN. STATE. ZlPI
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />
<br />Island Nebraska 68803-4050
<br />IENTER ONLY ONE CAUSE PER LINE FOR III. /llI, AND lell
<br />
<br />I WItvII~Qr'tHtIlfi(f~~'--'_..
<br />:-t" ......
<br />,
<br />
<br />_"_ontel_"';:;;;:~ _n
<br />
<br />Ibl
<br />DUE TO. OR AS A CONSEOUENCE OF-
<br />
<br />_-........... enn.,.";:
<br />
<br />'"
<br />
<br />210. INJU~Y AT WO~K 2ef. PlACE OF INJURY, Il. home, form. ......, I........
<br />D Dollie. 6uIldIng..... I~)
<br />
<br />Yell No
<br />
<br />
<br />leI
<br />PART OTltE~ _ICANT CONDITIONS - C-. eonlflbullng" "'" _ buI not..._
<br />
<br />"
<br />
<br />2$a
<br />
<br />o AcclclOnt 0 u_m;no<!
<br />o Sulcldl 0 Pondtna
<br />o HomiCide h'tVeAtigatlon
<br />
<br />26b. DATE OF INJURY IMo" Oay, Yr,) :!$c. HOU~ OF lNJU~Y
<br />
<br />2lIg. LOCATION
<br />
<br />STIlf'ET OR ~.F.D. NO.
<br />
<br />ClTY OR TOWl'l
<br />
<br />51~:;!'i.~
<br />
<br />
<br />210. DATE SIGNED (MIl" o.r. Yr./
<br />
<br />.. TM! Of' DEATH
<br />
<br />jUe
<br />~n
<br />
<br />1I
<br />
<br />2IC. PF\ONOIJNCED DEAD I*'. 0.,. Y,,)
<br />
<br />lid. .1'IlONOI/NCEI) DEAD /Hr....'
<br />
<br />M
<br />
<br />1I
<br />
<br />:280. On lhe _ cI.....- ""'0/ ~ 111".,...............0..
<br />.... -. -...,......, -.........-.-
<br />
<br />:lO,b WASC(lNSENTOMNTEO?
<br />.y 0 YES
<br />
<br />NO
<br />
<br />3'.~ AND ~S OF CE~TIFI IPHYSIC1AN. COAON~R'S PHYSICIAN OR COUNTY ATTORNEYI Iry,. Dr Pr/nrl
<br />~ G. J. Hrnicek. M.D., 729 N. Custer, Grand Island, NE 68803
<br />
<br />32. RfUI$TAAR
<br />
<br />~. DATI! FlU:D IlY REGISTIWI /MO. (lay. Yr.)
<br />
<br />FOR VITAL STATISTICS USE ONLY
<br />
<br />Place.......................A ..............,.....,...........B ........,..,_......._...........c ...............................,D ................................E ................................P
<br />art II......................TMV ......."",.,.
<br />
<br />NSC ..............................,.................,...,.................,......_.:.._;,..............................................................................................................
<br />................................................ Census Tracl No.
<br />
<br />Work..............................:....................................................................................................................................................................
<br />.......................................................................
<br />
<br />UC...............................................................................,.....................................................................................................................
<br />..................................,..................
<br />
<br />.R(iject..............u..............u....................~............................__...H_..............................................................;..............................,...........
<br />............;....."..~;......,.......,':"..,
<br />C Prin'''' w'"' MY ,""... rooyc.... ........ ' .
<br />
<br />I hereby certify this to be a true and correct copy of the original
<br />filed with the State of Nabraska
<br />
<br />A -<-'<' .-"";7,a?:7"v<---..--
<br />~1'Jt'1"/'//./~~-"'?'"<--
<br />
<br />
<br />by
<br />
<br />Notary Public
<br />
<br />
<br />I..... ttm 11/.. G GIENER.;L NOTARV..... Stat9(Jf ..Ne. b~..a.....s.k.a
<br />~ EARY L LOSCHeN
<br />My Comm. Exp. ~.02....,..,"i
<br />
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