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<br />'-
<br />
<br />WHlN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH'AND HUMA" SEfIlVlCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALS2GD1l&DNFlLE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA rISftGilJlldiiiJR;=WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. /:~~ ""~~=~{}i:~':~z..v
<br />
<br />
<br />''''{~/'; ~iW03 20060282 2 ~~s.<>p3,.""
<br />~~I$TX1iIatifT~E*7'SAR
<br />LINCOLN, NEBRASKA HEAL TH /fffJiWIIIAN SERVlCES$YBtEM
<br />.::!::-::. :'~~~~.,~~ ~.~:_.........,::.~'::.;t: ,,_~" ~- _.~,.-
<br />
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND~~~cis;i:N'~~~SUPPORT
<br />
<br />CERTI~~~;;~~~~EA~~~':-:; - .' -- 03
<br />
<br />14139
<br />
<br />56
<br />
<br />UNDER 1 YEAR
<br />5b, MOS. DAYS
<br />
<br />
<br />2, SEX
<br />
<br />3. OAT!;. OF DEATH (Month. Day. Y8ar)
<br />
<br />November 27, 2003
<br />
<br />1, DECEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />Ann
<br />
<br />C.
<br />
<br />Welch
<br />
<br />4. CITY ANO sr Are. OF SIFlrH (If (lat in U.S.A.. name country)
<br />
<br />Sa. AGE - Last Birtnday
<br />{Yrs.1
<br />
<br />UNDER. 1 DAY
<br />5<. HOURS' MINS.
<br />
<br />6. DATE OF BIRtH (Month. Day. Ye~r)
<br />
<br />Rapid City, South Dakota
<br />: 7. SOCIAL SECURTlY NUMBER
<br />
<br />: 506-62-4953
<br />
<br />: 8b. FACILITY. Name /1fr.otiflstitlJtion.giw;lsfret;ltanonumber)
<br />. St. Francis Medical Center
<br />.
<br />.-8"(:',- CITY, TOWN OR 1..0CATIO-N QF"De;A'fH
<br />
<br />December 20,
<br />
<br />1946
<br />
<br />Ba. PLACE OF DEATH
<br /> HOSPITAL: D Inpatient OTHE.~; D NurSing Home
<br /> ~ E.R Oulpall~nl D Resldenco
<br /> D DOA 0 Other (Specilvl
<br />
<br />10. RACE - (e.g., White. Black. American Indian.
<br />ote,IISDBeifyj White
<br />
<br />
<br />
<br />Be. INSIDE CITY LIMITS
<br />
<br />Ye,. ~ No D.
<br />OR LOCATION
<br />Grand Island
<br />
<br />80, COUNTY OF DEATH
<br />Hall
<br />
<br />Grand Island
<br />
<br />11, ANCESTRY (e,g.. Italian, Me)flcan. German, ate}
<br />(SpBeltv! Swedish
<br />
<br />
<br />68801
<br />
<br />90. INSIDE CITY l.IMITS
<br />Ve. 00 NO D
<br />
<br />9a. RESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />13. NAME: OF SPOUSE lit wile. give maiden name)
<br />Daniel L. Welch
<br />
<br />- 14a. USUAL OCCUPA TIQN IGive kind of work done during most
<br />I ofworkin.9'/~. evstlifretired} Teacher
<br />
<br />School
<br />
<br />15. EOUCA TION (Specify only highest gracle completed}
<br />i=Jementary or Secondary 10-12) College (1 -4 or S~ \
<br />4
<br />
<br />i 16. FATHER - NAME
<br />Clifford
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST 17 MOTHER
<br />
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />Swanson
<br />
<br />(NMI)
<br />
<br />Foley
<br />
<br />Ruth
<br />
<br />(NMI)
<br />
<br />- lB, WAS DECEASED EvER IN u.S. ARMED FORCES?
<br />(Yes. nO. or unk;,) (If yes, QlvQ war and dates 01 services)
<br />
<br />
<br />Daniel L. Welch
<br />
<br />MAILING ADDRESS
<br />
<br />{STREET OR R.F.D. NO.. CITV OR TOWN. STATE. ZIP)
<br />
<br />1032
<br />
<br />S
<br />
<br />Locust
<br />
<br />St. Grand
<br />~/OZ5'-t
<br />
<br />Island, Nebraska
<br />
<br />68801
<br />
<br />~ Burial D Removal
<br />
<br />
<br />CITY OR TOWN
<br />Grand Island, Nebraska
<br />
<br />STATE
<br />
<br />
<br />2'a. METHDD OFDISPOSITIDN
<br />
<br />Horne
<br />
<br />D CremiHion D Donation
<br />
<br />22b. FUNERAL HOME ADDRESS
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP}
<br />
<br />3213 W North Front
<br />
<br />St., Grand Island, Nebraska
<br />IENTER ONLY ONE CAUSE PER LINE FOR 1.1, Ib}, AND (ell
<br />
<br />68803
<br />
<br />:26a.
<br />
<br />26b. DATE OF INJURY (Mo.. Day, y,) 2Be. HOUR OF INJURY
<br />
<br />
<br />I Interval between onset and deall1
<br />I
<br />: IMMEDIATE
<br />
<br />I Interval between onsel (3nd dealh
<br />I
<br />I
<br />I '~""'--.."..-,-
<br />I Inte(val between onset and death
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />.
<br />.
<br />.
<br />
<br />23. IMMEDIATE CAUSE
<br />~m CARDIAC ARREST
<br />181
<br />DUE TO, OR A~ A CONSEOUENCE OF
<br />
<br />~
<br />
<br />I"'
<br />DUE TO, OR AS A CONSEOUENCE OF'
<br />
<br />lo)
<br />PART OTHER SIGNIFICANT CONOtilONS - Conditions. contributing to the death but not related
<br />
<br />"
<br />
<br />o Accident 0 Undetermined
<br />D Suicide D F'ending
<br />o Homicide Investigation
<br />
<br />26e. INJURY AT WORK
<br />Yes D No D
<br />
<br />269, LOCATION
<br />
<br />STREET OR R.F,D, NO,
<br />
<br />CITV OR TOwN
<br />
<br />STATE
<br />
<br />27e. TIME OF DEATH
<br />
<br />
<br />2Ba. DATE SIGNED (Mo..Oay. y,.)
<br />
<br />2Bb. TIME OF DEATH
<br />
<br />278. DATE OF DEATH (MO.. Day. Y'I
<br />
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due 10 the
<br />cause/51 staled.
<br />
<br />Zi;;
<br />i<"~~
<br />h@>- 2B<
<br />8 "," ~
<br />llffi~
<br />~L
<br />85
<br />
<br />9: 41 A
<br />
<br />: E~
<br />."i~
<br />-Q)~~
<br />- 1.. Z
<br />- '-' E'O
<br />-1l'E
<br />.: S':!:
<br />J ~
<br />I
<br />
<br />M
<br />
<br />27b. DATE SIGNED (Mo.. Day, yo
<br />
<br />PRONOUNCED DEAD (Hou'l
<br />
<br />M
<br />
<br />M
<br />
<br />. J .LSi nature and Tille) .. .
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />DYES D NO Qg UNKNOWN
<br />31. NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONER'S PHYSICIAN ~FOUNTY ATTQBti8W ITy"" 01' P,in/I
<br />JEROM E. JANULEWICZ, 231 S LOCUST ST, GRAND ISLAND NE 68801
<br />
<br />KJ NO
<br />
<br />J2a. REGISTRAR
<br />
<br />
<br />
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