|
<br /> 0~~ .-..:>
<br /> HOs- :lIIQ n () ~ C') (j')
<br /> m :t: > = 0-4 C)
<br /> ~(J\):t:: "'Tl c=r.> gt
<br /> C m c.n ...... ~ c:::l> N
<br /> n ::I: ,...-) , C- z-4
<br /> l7\ ~ U- nn6 A ~ ~' c:= -Jifl C) fiT
<br />I\,) <.....n I -<0 it
<br />s B- -t:... '". ~>~ ~,{'- ....... 0"'" 0
<br />S N :$ n c.n 0 ..."
<br />0') C><1 -.J)VI :::c ""T1 Z- en
<br />S ~ ~ r :r: rr1 G;-
<br />O') ('J Cl l> co C)
<br />-->. rn -0 r- :::0 -
<br />S U\ rn :3 0) ::J
<br /> Cl r :>
<br />ex> 0 (J1 ....... (j') g
<br /> ~
<br /> ~ N ;;:0;:
<br /> l> 0 ~
<br /> C...:l ~'...........,
<br /> W (f) 0)
<br /> '" ,....
<br /> .,2,' Z
<br /> -.iJ
<br /> ,.,
<br />
<br />
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM. "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM. VITAL STATlSTQSECiiliN,'WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ./;~~~;:;.:C::'~-';";','=-:,", ,_
<br />
<br />DATEOFmSUANCE M~~~
<br />1!,1:;.,,~:u. 20060610 8 HEAL7H_.~
<br />
<br />.. .. .___on..". ,.~.. -=', '. -.:;.~. .,.. .., '. ,-..,;-c ".
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND~,s~~EfN~A!'!DSpjPoRT
<br />CERTI~~;~rg~riE~riI~'~;;;~",'~'-~":~ "."/"- 04
<br />
<br />5,50
<br />
<br />08212
<br />
<br />1. '-6eCgDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH IMonth. Day. YaarJ
<br />
<br />Frances
<br />
<br />Elizabeth
<br />
<br />Niedfelt
<br />
<br />Female
<br />
<br />July 22, 2004
<br />6. DATE OF BIRTH lMon'I!. Day. Yaarl
<br />
<br />4. CITY AND STATE OF BIRTH III noti<> U.S.A.. nam. c""n/ty)
<br />
<br />5.. AGE - Lao' Binhday
<br />IY".I 88
<br />
<br />a.. PLACE OF DEATH
<br />
<br />UNDER 1 YEAR
<br />5b. MOS. DAYS
<br />
<br />UNDER 1 DAY
<br />5c. HOURS' MINK
<br />
<br />November 18, 1915
<br />
<br />Comstock, Nebraska
<br />
<br />. 7. SOCIAL SECURTIY NUMBER
<br />
<br />506-28-2763
<br />
<br />HOr;:PITAL; 0
<br />
<br />o
<br />o
<br />
<br />Inpatient OTHg,:<, 0 NurSing Home
<br />ER Outpatient IKJ Residence
<br />DOA D O'her ISpeedV'
<br />
<br />6b: FACILITY. Nam. (II no/ msU/uIIon. glve.moet and n_1
<br />
<br />215 E. 16th
<br />
<br />Czech
<br />
<br />
<br />Hall
<br />
<br />ac. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />ad. INSIDE CITY LIMITS
<br />
<br />Grand Island
<br />
<br />Hall
<br />
<br />68801
<br />
<br />90. INSIDE CITY LIMITS
<br />Yes 00 No D
<br />
<br />Nebraska
<br />
<br />
<br />90. STREET AND NUMBER (Including Zip C_,
<br />
<br />9.. RESIDENCE. STATg
<br />
<br />10. RACE. le.g., White. Black. American Indian.
<br />e'e.IISp.CIIYI Wh i t e
<br />
<br />11. ANCESTRY le.g.. Italian. Mexican, German, Gtel
<br />(Speelfy)
<br />
<br />13. NAME OF SPOUSE III wifB. give maid8f1 name)
<br />
<br />
<br />~fa
<br />I}->-;"-
<br />: 8 5: ~
<br />1~1
<br />
<br />M
<br />
<br />~.......IU...". ..............
<br />; .',..~...... .-....\
<br />'..'''i'',A;:;
<br />.... ..6#." ..
<br />'Q,';I;k:>...\
<br />-=.D44i:!I:..
<br />"12. ...:t'j:
<br />'l..;....................:Q..'
<br />__. .t..\
<br />:,0".-:1"" .
<br />rA.:......_:td.
<br />.."..J.4 ~'1lS
<br />!Q)Gn~
<br />t>
<br />.! ftJG.l ...
<br />.'. .M
<br />"......'.'...8.'. 14: it
<br />. .
<br />.... .'Ol
<br />'g. .......+'. ...~......... '. ~..'
<br />, ::/11:'
<br />... '.10 :5
<br />$ ....
<br />.iJ.' .... ,"~.'., ..........~. '.' ..
<br />...... .\0
<br />..~
<br />~&r~ ~
<br />:JtI--
<br />O.c~l44
<br />Cf) <lJ ~. 0
<br />II 'H. ..:U
<br />iO~CD
<br />~;o.j~
<br />~. ~"'"
<br />O.~'. '.' .
<br />.. '.' . . '>if;;
<br />,"-I ,~.___
<br />r-4 g'~
<br />.' .. ......
<br />\I" ...... .~....1l
<br />: ." ;J) fofa .
<br />''.4-1.. w .... cO
<br />:~~Q ~,)t.
<br />=.aJ..... ,~.'..>d...~........ OJ:
<br />:' ~.... b'>)..j
<br />"&.l' u.c:;....
<br />'..1;. 0 Q) cQ ij;
<br />&of f.f,Utt ~ :z
<br />
<br />
<br />16. FATHER - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />Domestic
<br />LAST
<br />
<br />15. EDUCATION (Specify only highElst grade completed)
<br />Elementary or Sef5ndary IO"1~1 College (1-4 or 5"1
<br />
<br />14a. USUAL OCCUPArlON IGive kind 01 WOfk done dlJrlfl!1 most
<br />of worki~~ Jim. 8V8fl If retlredJ
<br />tlomemaker
<br />
<br />H.
<br />
<br />
<br />\ 7. MOTHER
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />John
<br />
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />lYes. 110. or unk.) (If yes. give war aoo dates of servicesl
<br />No
<br />
<br />Pauline
<br />
<br />E.
<br />
<br />Moravec
<br />
<br />Francie Ballou
<br />
<br />-'9b. INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />(STREET OR RF.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />Grand Island, NE.
<br />
<br />68803
<br />
<br />4145 W. Airport Rd.,
<br />
<br />; 20~:SIGNAT~A~;O ;# /s~s-
<br />
<br />: 220. FUNERAL H E - NAME
<br />
<br />210. METHOD DF DISPOSITION
<br />
<br />21b. DATE
<br />
<br />21c. CEMETERY OR CREMATORY NAME
<br />
<br />[19 Burial 0 Removal
<br />
<br />Jul 27, 2004 Westlawn Memorial Park
<br />21d. CgMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Apfel.,.Butler-Geddes 0 CromaliOn D DoMI,pn
<br />.. 22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />Grand Island, NE
<br />
<br />
<br />Second,
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />~~C.
<br />
<br />IENTER ONLY ONE CAUSE PER LINg FOR 1.1. fbl. AND (ell
<br />
<br />Interval between onset and death
<br />
<br />Z -3 It4
<br />
<br />Interval between onset and deall1
<br />
<br />Ib)--- .
<br />DUE TO, OR AS A CONSgOUENCE OF
<br />
<br />IntB'(val between onset and deatll
<br />
<br />o Accident 0 Undetermined
<br />D Suicide 0 Pending
<br />o Homicide Investigation
<br />
<br />268. INJURY AT WORK
<br />vesD NoD
<br />
<br />
<br />26g. LOCATION
<br />
<br />STREET OR RF.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />lei
<br />PART OTHER SIGNIFICANT CONDITIONS - ConditionS contributing to tne deatn but not relatMI
<br />
<br />II
<br />
<br />26..
<br />
<br />26b. DATE OF INJURY IMo.. Day. y,! 260. HOUR OF INJURY
<br />
<br />27.. DATE OF DEATH {Mo.. D.y. Yr.}
<br />
<br />28e. DATE SIGNED (Mo.. Oav. Yr.)
<br />
<br />28b. TIME OF DEATH
<br />
<br />m
<br />
<br />$~~
<br />l~~
<br />Ii:,.
<br />~ig
<br />~~~
<br /><.> 0
<br />
<br />M
<br />
<br />July
<br />
<br />22,2004
<br />
<br />2ac. PRONOUNCED DgAD (Mo.. Oay. Yr.)
<br />
<br />28d. PRONOUNCED DEAD (Houri
<br />
<br />M
<br />
<br />288. On the basis of examination and10r investigation, in my opinion death occurred at
<br />the time. date and place and due 10 tl'l8 caUSEI(S\ stated.
<br />
<br />I NO
<br />
<br />JO.b wAS CONSENT GRANTgD?
<br />D ygS
<br />
<br />~NO
<br />
<br />Grand Island, NE 68803
<br />32b. DATE FILED BY REGISTRAR (Mo.. Oay. Yr.)
<br />
<br />
|