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<br />'WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ~'SERVlCES
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINMiIf~ ON.lti:.e--,WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA 1f$TJC$SECTlON, 'WI:lICli IS
<br />
<br />:1ELE~:::mroRYro;;~;~26 ~~~
<br />
<br />MAR 6 2000 AS3litANT STATEREGiSiMR
<br />LINCOLN, NEBRASKA HEALTH AND'HpMAN'jl!~''sY~M
<br />STATE OF NEBRASKA- DEPARTMENT OF HFALTII AND HUMAN Sil\\l'fCES !lNANafi' ~iUPPORT
<br />VITAL STATlSTICS-'::'".~___, ._.,c:;'c--
<br />CERTIFICATE OF DEATH-"=::"~
<br />
<br />5~ S c:>
<br />
<br />1 Ofc!:m:N r - NAME
<br />
<br />_.""FIRST
<br />
<br />
<br />November 28.
<br />
<br />1927
<br />
<br />MIDDL~
<br />
<br />LAST
<br />
<br />, sEX
<br />
<br />--~-----_. . .~_..._---'----
<br />3 DATI: Oi= DEATH IM)Il(h O,Jv YPilf}
<br />
<br />Glenn Eugene
<br />TCITY ANti STATE OF AIRTH (If nof 1(1 ~i'i's A,. name covn!ry/
<br />
<br />Raubold
<br />
<br />.. -'~_.--r' 3, "AOf: - Lasl Birthdav
<br />1Yrs I
<br />72
<br />,.-","_._-,..-
<br />
<br />Male
<br />
<br />March 1. 2000
<br />6. DATEOF ~IRTH (Month Q,:Jv, YOi1f!
<br />
<br />UNDER i YFAR
<br />5t) MOS I DAYS
<br />I
<br />
<br />Palmer. Nebraska
<br />?SOCIAl ~~CU'RTIY NUMBfH
<br />
<br />8a PI.ACE OF DEATH
<br />~.9SPIT A~. [] Inpi;lhenl
<br />D E R OUlpatienl
<br />D DOA
<br />
<br />OTHf-H D NurSing Home
<br />
<br />D Resl(iBnCe
<br />
<br />D Other (Specdy! _"n
<br />
<br />723-03-6369
<br />
<br />8b f' A(:lL1TY Name
<br />
<br />(If not msflfuf,M:'.give street rind number)
<br />
<br />St. Francis Medical Center
<br />BcCi'TYTOWN"OR LOC^ TION OF OEA n:;
<br />
<br />
<br />[Sa INSIDE CITY LIMITS
<br />
<br />Yes IX] No 0
<br />CllY. TOWN OR LOCATION
<br />
<br />9d sr~EEl AND NUMBER /lm::lurltngZlp Ox/aJ I 9~~ INSIDF. tllY LIMITS
<br />
<br />68801 Yos IXJ No.D
<br />
<br />13 NAME OF SPOUSE (If wife. qlV'B maiden (J(w'I8)
<br />
<br />Grand Island
<br />
<br />
<br />9a RE-510ENCE - STATE
<br />
<br />Nebraska
<br />
<br />",Ie IISOCCltyl
<br />White
<br />
<br />11 ANCESTRY (e,g 11aliari, Melocan. German. elc!
<br />(Spe(:lly) American
<br />
<br />- ..
<br />1~, EDUCATION (Specify o.~IV highest grade completed) ~~__'_
<br />fterilthr SG~did(~ 12) College r 1 _il D' ~. I
<br />
<br />MIDDLE MAIDFN SlJRNAME
<br />
<br />Annie Mae Rasmussen
<br />
<br />-.----..
<br />14J USUAL OCCuPATION /GIve kind of work done during most
<br />of working Ide. everl /f tatll-edl
<br />
<br />Truck Driver
<br />
<br />Over The
<br />LASl
<br />
<br />17 MOTHER
<br />
<br />16FAf~ME
<br />
<br />"FIRST ..._~.. MIDDl.~
<br />
<br />Charles
<br />
<br />Haubold
<br />~i'Nf'ORMANT
<br />I
<br />
<br />Edna~_ _~aude ....._~~.EY_~____._
<br />.NAME- -. .. ._-
<br />
<br />18 W~.:'-DEC=:At~ED E:.vU, 1:~ I; S AP.M~[l FORCF.S?
<br />i','~~, ,0 '.! '.JI'v:',1 I HI Y(!,!>, ql\l~ '''ar ancl dales 01 services)
<br />
<br />~ .-----.L..._---=-:--=::---
<br />19b INFOHMANT MAILING ADDRESS
<br />
<br />Annie Raubold
<br />
<br />ISTRE~T OR HF D NO CITY OR TOWN. STATE,llPI
<br />
<br />
<br />Island,
<br />
<br />Nebraska 68801
<br />-21a METHOOQFDtSPOS1TIQN 21b DATE &~-~_."'.'~~M8E~EMA1()H-Y.--~~AMF-
<br />I
<br />lliJ "un" 0 Remo'al Mar. 3, 200~~l::lod Cemetery
<br />21d. CEMnERY DR CR~MATORY LOCATION CITY OR fOWN
<br />
<br />STATI:
<br />
<br />*1143
<br />
<br />D Cremation D Dooatton
<br />
<br />St. Paul~ Nebraska
<br />
<br />Livingston-Sondermann F.R.
<br />22b HJNERAL HOME ADDRESS {STREET OR HF.D. NO.. CIW OR TOWN. STATE. liP}
<br />
<br />Grand Island, Nebraska 68803-4050
<br />{ENTER ON, Y ONE CAUSE PER LINE FOR ,., ibI. AND lell
<br />
<br />601 N. Webb Road,
<br />
<br />~P~R:a:MMEDIATE CAUt \J i\
<br />
<br />-------OUE TO. OR AS A CONSEOUENCE or
<br />
<br />(~~IIF T.) OR AS ~N~~~ ~ i;)" '3,,-
<br />
<br />I Int@rval between OnS€l aM (jp;Hh
<br />I
<br />: ,~ 1~~J:!,':tand;;~
<br />
<br />I
<br />I
<br />
<br />I Intl;!~"al balween onset and death
<br />I
<br />I
<br />I
<br />25 WAS CASE RFFERRED TO MEDICAL'
<br />.....(J FXAMINER OJ=.! CORONER-/
<br />Yes n No ,~.
<br />
<br />lei
<br />OTHfR SIGt:)CANT CONDITIONS Conditions conlributing 10 the d@athbutnotrelated
<br />PART
<br />
<br />~._......,._ . A.~~~~
<br />
<br />26a 26b OATF OF INJURY HOuR OF INJURY
<br />
<br />o Accident
<br />
<br />[I
<br />o
<br />
<br />
<br />2Bb TIME OF [)F:ATH
<br />
<br />PART III IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PREGNANCY IN TH( PAST 3 MONTHS? .,.
<br />
<br />(Age!; 10-~41 Yes n ~~~ n I Yes,
<br />261::1. DESCRIRF. HOW INJlHW ocCu~RED
<br />
<br />
<br />o Undele<m,,,eu
<br />[] pp.nrllflq 2f)~? INJU~Y It. T WORK ~.
<br />lr1v(tS'lga'~__,_V~~_ D No D
<br />27a DATE OF OEA TH /Mo Day. Yr.}
<br />
<br />.,~-,.
<br />CITy OR lawN
<br />
<br />SlJ,~.,de
<br />
<br />"~~-- --~,"'._'---" -----
<br />26g LOCA nON STREE::l Oi=-l n F [J NO
<br />
<br />STArE
<br />
<br />HOIT\lcloe
<br />
<br />2Ba~"'~N~U-./Mo" Dav Yr,}
<br />
<br />t5':i
<br />i ~;.. 27b DATE SIGNED (MO
<br />
<br />5 ~~ --
<br />~i
<br />~." ~
<br />
<br />
<br />(..u r k () ::s
<br />-- -"
<br />
<br />0'>
<br />
<br />M
<br />
<br />:>-,< UJ
<br />~~~
<br />1'<1=>
<br />a...q:....i
<br />~t::5
<br />s~'5
<br />~~8
<br />u 1:';,
<br />
<br />,8< PRONOUNCED DEAD {Me Day, Yr.I
<br />
<br />28d. PRONOUNCf.D DEAD (Howl
<br />
<br />270 TIME OF DEATH
<br />
<br />~..,,--\
<br />
<br />~-
<br />
<br />M
<br />
<br />M
<br />-~-- ._-~,-~"-'---
<br />
<br />26e On lhe oasis 01 eXi;lmlrlatlofl and or lnveshgalion, in my opinIon dealh ocr:urrOO at
<br />the lime, dale and place and due 10 the cause(s\ Slaled.
<br />
<br />.27cJ 1 () the best of my kMw
<br />..... CCll,se(!5) slaled.
<br />
<br />(51 nature 3m,i Til10) ..
<br />29 DID TOBACCO USE CONTRtBLJlE TO THE D~A TH?
<br />
<br />..t' D Y~S ~ D UNKNOWN
<br />
<br />31 JiIIM.EAND ADDRESSOF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY A TTORNfYI {TYPB!,,!:!'.~lj
<br />
<br />-( \
<br />
<br />30.0 WAS CONSENT GRANTED?
<br />'C' D
<br />. YES
<br />
<br />LANO
<br />
<br />'7 p.. q
<br />
<br />~
<br />.';:,sl.,_
<br />
<br />32.
<br />
<br />
<br />f.v'u ~{1 '\
<br />
|