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<br />.5
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUNAN SERVICES
<br />SYSTE~ "CERTlFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RfCQ8clc:iNFiILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAJ/!dl~,~ WHICH IS
<br />
<br />:::~::~::::::TORYFOR VITAL RECORDS. . ;M.--;^:~t~-:"-;'~ 7J~~....~. _~
<br />6/8/2004 20060442 gzr;j:w;'i:==
<br />LINCOLN, NEBRASKA 5 HEALTft:ANl>:=~'J1Y1JTeM
<br />-\'{'i- ..'':~'---,:0..::.:' .. .,.7j;" i-
<br />STAlE OF NEBRASKA- DEPARTMENT OF HEALtH AND Hl1MAN~cali.iN~ANli SUPPORT
<br />VITAL STATISTICS -,~ :-:,~,,_~,'.'S'-':"- 0 4 0 6 0 9 6
<br />CERTIFICATE OF DEArit~,<,.~t2;:'"~:;'''~'
<br />
<br />." DECEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />
<br />2,SEX
<br />
<br />3. DATE OF DEATH (Month. Day. Year)
<br />
<br />Ilene
<br />
<br />Margaret
<br />
<br />Crick
<br />
<br />Detroit. Michigan
<br />
<br />7, SOCIAL SECURTIY NUMBER
<br />
<br />Sa, AGE. Last Birthday UNDER 1 YEAR
<br />(Y",I ~6 5b, MOS, I DAYS
<br />
<br />8a, PLACE OF DEATH
<br />
<br />UNDER 1 DA V
<br />5e, HOURS' MINS,
<br />
<br />May 21. 2004
<br />6, DATE OF BIRTH IMont ~~ '1"')
<br />
<br />May 29. 2004
<br />
<br />.~'-CTT'(. AND STATE OF 6JRrH (If not in U.S.A.. nam8 coontry)
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />
<br />HO~P!T AL: 0 Inpalient OTHER: rxJ NurlSing Home
<br /> 0 ER OUlpallenl 0 Residence
<br /> 0 DOA 0 Other (SP~f;tfVI
<br />ad, INSIIJoE-CrTV LIMIT-S--'
<br />
<br />369-24-2941
<br />
<br />8b. FACILITY. Name
<br />
<br />(If not institution. giV8 street and numb8r)
<br />
<br />Beverly Health Care: Lakeview
<br />
<br />ac.--UrV'-.TOWN OR LOCATION OF DEATH
<br />
<br />Grand Island
<br />
<br />Hall
<br />
<br />
<br />9a. RESIDENCE - STATE
<br />
<br />8d, STREET AND NUMBER (Including Zip Cade)
<br />
<br />90. INSIDE CITY LIMITS
<br />
<br />White
<br />
<br />11. ANCESTRY (e.g..ltalian. Mexican, German, atcl
<br />ISpee'I\<J .
<br />lUIlerlCan
<br />
<br />15th St. 68801 ve.1XJ NO 0
<br />13. NAME OF SPOUSE (If witfl. give maiden name)
<br />
<br />14., USUAL OCCUPATION {Wve kind ol_k done during most
<br />of working lif8, even If retireel}
<br />Owner/Operator
<br />
<br />16, F ATHER. NAME FIRST MIDDLE
<br />
<br />17. MOTHER
<br />
<br />15. EDUCATION {Spoc,ty only highest grade eompletOdJ
<br />Elementary or f~Ondary 10-121 College 11 -4 or 5+ I
<br />
<br />MIDDLE MAIDEN SURNAME
<br />
<br />1a, WAS DECEASED EVER IN U,S, ARMED FORCES?
<br />(Ves. no'N Ok.) (11 yes. give war and dates of servlcesl
<br />
<br />Mike Crick
<br />
<br />,Z':i
<br />
<br />IIi
<br />~f
<br />
<br />
<br />M
<br />
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<br />
<br />191>, INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />414 W.
<br />
<br />15th St..
<br />/Z-'ICJ
<br />
<br />Grand Island, NE. 68801
<br />21.. MEJ'HODOFDISPOSITION 21b, DATE
<br />
<br />21e, CEMETERV OR CREMATORY NAME
<br />
<br />
<br />[]J BUo1aI
<br />
<br />o Removal
<br />
<br />May 25. 2004
<br />
<br />Westlawn Memorial Park
<br />
<br />21d, CEMETERY OR CREMATORY LOCATION
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />Apfel-Butler-Geddes
<br />
<br />o Crematlor'l 0 Oonallon
<br />
<br />Grand Island. NE
<br />
<br />22b. FUNERAL HOME ADDRESS
<br />
<br />(STREET OR R.F.D, NO" CITY OR TOWN, STATE. ZIPI
<br />
<br />1123 West Second.
<br />
<br />Grand Island. NE.
<br />
<br />6880 L
<br />
<br />(el -(C{l!.e. II d((;t..b~ks
<br />OTHER SIGNIFICANT CONDITIONS. Condlllon. eontrlbuttng 10 1ho doal/l bUl "'" r~
<br />PAffrel,rdl1,.c.. (!-t!rt! /;rOVax.u.t..a.r //?Su+f/~~n
<br />'4 '0 ~t7rt7. r. ,. ~.sl...
<br />28., 2Gb, DATE 28e, HOUR OF INJURY
<br />
<br />~D
<br />o
<br />o
<br />
<br />Accident 0 Undetermined ....----.
<br />Suicide 0 Pending
<br />lotOmicide Investigation
<br />
<br />
<br />I
<br />I
<br />i
<br />I
<br />I
<br />I
<br />
<br />epH7jJtoJ,;'/lS:
<br />
<br />I
<br />I
<br />I
<br />I
<br />25, WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />Interval between onset and dealh
<br />
<br />23, iMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la\. Ib). AND {ell
<br />PART "
<br />I{al ml.<:l4t.....l./s+-<'" +~ll,..(,.re..
<br />DUE TO. OR AS A CONS~OUENCE OF
<br />
<br />{bICf:,(lUtLl Iud ayt.er/oscluos"s and k/l5~ term tliabt't,c
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />c..u e ~ K:.. s
<br />
<br />Interval between 0f18et and death
<br />
<br />4'-ear s
<br />
<br />In1erval between onset .and deatl1
<br />
<br />26g, LOCATION
<br />
<br />STREET OR RF.D, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27., DATE OF OEA TH IMo., Day, Y'I
<br />
<br />S,- 1-\- C,\
<br />
<br />26a, DATE SIGNED (MP" Day, Yr.l
<br />
<br />28b. TIME' OF DEATH
<br />
<br />27b, DATe SIGNED {MD.. Dey, YO
<br />
<br />27e, TIME OF DEATH
<br />
<br />4:30
<br />
<br />28e, PRONOUNCED DEAD (MD., Day. y,)
<br />
<br />28d, PRONOUNCED DEAD (Houri
<br />
<br />P M
<br />
<br />M
<br />
<br />28e, On the basis of G:lIsmination and/or investigation. in my opinion death OCCl,lfl'Etd at
<br />tne time. date and ~ace and due to the cause(s) stated.
<br />
<br />30,b WAS CONSENT GRANTED?
<br />o YES ~. NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER {PHVSICIAN. CORONERS PHVSICIAN OR COUNTY ATTORNEY I ITYIM Dr Print)
<br />
<br />Steven L. Husen M.D.
<br />
<br />
<br />Grand Island. NE 68803
<br />32b, DATE FILED BVRE:rUN (MD--r ~004
<br />
<br />32., REGISTRAR
<br />
|