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<br />
<br />Rev, 11197
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<br />20060667
<br />
<br />1 STA 1E OF NEBRASKA- DEPARTMENT OF HEALTI:I AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />1. llFCEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIOl.JLE
<br />
<br />I.AST
<br />
<br />2 S~X
<br />
<br />~. DATE OF OEATH {Month Day. YliJar!
<br />
<br />Edwin
<br />4 CITY ANO STATE OF BIRTH ilf not m u.8.A.. flame caU1Jtry}
<br />
<br />3, 2003
<br />6. DAll:: O~ BIAlH tMonth. Day~";ea,""'---'-------~'--".--'--'
<br />
<br />Elias
<br />
<br />Baker
<br />
<br />Male
<br />
<br />
<br />5a'~-Am; - Last Birthday
<br />{Y,,' 86
<br />
<br />UNO~R 1 YEAR
<br />5b MOS I DAYS
<br />I
<br />
<br />UNDER 1 DAY
<br />5c, HOURS MINS
<br />
<br />April 4, 1917
<br />
<br />Phillips, Nebraska
<br />7 SOCIAL'SECURTIY'N'UMiiER"
<br />
<br />8. PI,ACE OF DEATH
<br /> HOSPITAL; D Inpiiltienl 2:!:~ER 51 NUr!i:lnq Homt:!
<br /> 0 !;R Ol,l1pa,tienl D RSSldarlC8
<br /> D DOA D Olher ISpe/:II',I1
<br />
<br />. 506-16-3591
<br />
<br />
<br />8b. FACIUlv - NarM
<br />
<br />(Ifnot InstiiIJlian, 9/vs street and numbBr)
<br />
<br />Veterans Affairs Medical Center
<br />Be. CITY TOwN OR LOCATION OF DEATH
<br />
<br />
<br />Bd INSIDE CITy liMITS Be COUNTY OF DEATH
<br />
<br />Grand Island, Nebraska
<br />9.. RESIDENCE - STAT"
<br />
<br />Hall
<br />
<br />STREET AND NuMBER (/ncl~di;:'g Zip COGel
<br />
<br />ge IN$IDE CITY l.IMITS
<br />
<br />10.
<br />
<br />
<br />'3 NAME:; OF SPOUSE Iff WIfe, give maiden IlElmt;l)
<br />
<br />Nebraska
<br />
<br />68801
<br />
<br />Yo, IX] No D
<br />
<br />11, ANC~STFl.Y (fI.g Italian. Me)(lcan, German, etc)
<br />ISpeclfy)
<br />
<br />otc.IISpoc'fyl Wh i t e
<br />
<br />American
<br />
<br />Roberta
<br />
<br />14a uSUAL OCCUPATION IG/v/:' kind of wofk done auring mu!Of
<br />01 wmhlllg li(8, BI/On /1 retiredl '
<br />
<br />Security ,Guard
<br />16 fATHER - NAME FIR~T
<br />
<br />1 s, EDuCATION (Speclly only highest graOA tOn,pI9t~~L~.
<br />Elementary or Seconr.lary 10-121 College 11.4 Dr :,~ I
<br />12
<br />
<br />Ordnance
<br />-CA51'-
<br />
<br />
<br />MAIDEN RURNA~"
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />1"1 MOTHER
<br />
<br />MIDDLE
<br />
<br />R.
<br />
<br />Pur~y
<br />
<br />Harriet
<br />
<br />Leon
<br />
<br />J.
<br />
<br />1 B WAS DECEASED EVER IN us AAMEir FORC~S?
<br />
<br />[Y"Ye~unkl wa'ry"'i""!l"94'3:"tO/1945 Leon Baker
<br />
<br />,gb INFORMANT MAILING ADPRESS ISTREET OR A.F.D. NO.. CiTY OR TOWN. STATE ZIPI
<br />
<br />Leon Baker
<br />
<br />20. EMBALMER. SIGNATUHE & LICENSE NO
<br />
<br />1111 West Ash Blytheville, Arkansas 72315
<br />21"'METHOD OF DlSPDSITION 21 D 6A TE, 21< di.ETERY OR CREMA TORY '~NAME
<br />
<br />Not Embalmed
<br />22. FUNERAL HOME - NAME
<br />
<br />Daurlal
<br />
<br />October 6, 200 Westlawn Memorial Park
<br />21d. CEMETERY OR (REMATORY LOCATION CITY OR TOWN .,~~
<br />
<br />D Remov;;:I1
<br />
<br />[Xl Cremation D Doniillon
<br />
<br />Grand I~land, Nebraska
<br />
<br />Livin ston-Sondermann F.H.
<br />220 'uNERAL HOM~ ADDRESS [STREET OR R.'.D. NO.. CITY OR TOWN. srATE, ZIP)
<br />
<br />Livingston-Sondermann F.H.
<br />
<br />23 IMM~DIATE CAUSE
<br />PART
<br />X I 1., Apnea
<br />"O'UE TO, OR AS A CONSEOUENCE OF
<br />
<br />601 North Webb Road Grand Island, NE.
<br />(ENTER ONLY ON!::. CAuSE PER I,.INE FOR lal, Ibl. AND (ell
<br />
<br />Inlefval between o.;;~--
<br />
<br />68803
<br />
<br />26c. HOUR OF INJURY
<br />
<br />
<br />Weeks
<br />WAS CMiER""ERRED TO MEDIC'AL
<br />EXAMINER OR CORONER"
<br />Y"~, n No LXl
<br />
<br />
<br />Seconds
<br />
<br />Inl91vaJ between onsel and dl::!<j(\'1
<br />
<br />X Hours
<br />
<br />~ Dehydration
<br />DUF TO, OR AS A CONSEQUENCE OF
<br />
<br />Inlervi;l.1 halween onset and Cleol/l
<br />
<br />'f..
<br />
<br />Pancreatic Cancer
<br />
<br />[el
<br />OTHER SIGNiFICANT CONDITIONS Conaillans contributing to the death !;ILlt not related
<br />PART
<br />II
<br />
<br />26.
<br />D ACCident D
<br />D SUIcide D
<br />D Humlcide
<br />
<br />:25b PATE OF INJURY
<br />
<br />
<br />2ao TIME OF DEATH
<br />
<br />UndetBflTllf\8d
<br />
<br />M
<br />261. ~ffi~i~u~~i~~~~~Y fff~~r farm. ~1ree1. lactor'y
<br />
<br />26g. LOCA liON
<br />
<br />STREET OR H,F,U. NO.
<br />
<br />CITY OR rOWN
<br />
<br />STATE
<br />
<br />Pending 26e. INJUFlY A l WORK
<br />
<br />Inve511ga1lon Yes 0 No 0
<br />
<br />
<br />'27. DATE OF DEATH (M".. Day y,)
<br />
<br />2a. DATE SIGNED 'iMo Day YO
<br />
<br />
<br />October 3, 2003
<br />
<br />27b. DATEloTo~lo~' Yr.)
<br />
<br />Z :-
<br />i5'Q~
<br />ij!i?o
<br /><S.~~~
<br />8:q~o
<br />Hg
<br />8 "
<br />
<br />M
<br />
<br />TIME OF DEATH
<br />
<br />2ac. PRONOUNC~D DEAD (Mo Day, Yr.)
<br />
<br />280. PRONOUNCED DEAD {Hour!
<br />
<br />M
<br />
<br />___L-
<br />
<br />2&:1. On the basis of examinatIon Cincl'o( investigation, in my OplrlloO deatn occurred al
<br />1M time, date and place and due to the cause(slslated.
<br />
<br />Iho
<br />
<br />SO.b WAS CONSENT GRANTED'
<br />
<br />DYES
<br />
<br />00 NO
<br />
<br />x
<br />
<br />31 NAMEAND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY I IType'" P"nl)
<br />
<br />H D ') I 0 \ N iS~<oAD \LiELL
<br />
<br />x
<br />
<br />\/ I S~~ LAV
<br />
<br />DRINCIC
<br />
<br />61\AND ~~lAN\\Nf'1 6ggo.s
<br />
<br />32b DArE FILED BY REGISTRAR (Mo.. Day Yr.)
<br />
<br />32. REGISTRAR
<br />
<br />FOR VITAL STATISTICS USE ONLY
<br />
<br />Place .................,....A .."......"..."....".,.......B ..,..........".....,....,..,C .................""".. .....D ..,...."..........."",......E ".".",..."."..... ........Part II
<br /> """.. ..........,TMV ,,,,,....
<br />
<br />N SC ."".,,,..,..........,,.,.,,.,,.,,........., '" "..,,,,,,............,.,,,,, "" ",...".......... ,...,..,..,...."..,.", "'" ........,..."..,."."..,..,.."..,.." ........"..,..,....."
<br /> ......,............."." "., ". . ......... Census Tract No.
<br />
<br />W 0 r k ..."..., ........,."."",."",........,.,..,.".............."..,."",.",.,......,....,..,.,',....,.........,.,",..,' ,......,..,."..,..,..,.....,.... ..,..,."""."",.". ......,..,..,..,..,...".""
<br />"".. .......,.."..."""",.,."."..,...
<br />
<br />U C..,.",...................,....,..,.",.., .......,..""."....,.. ....,..".,.".,.."..".. ......."."..,...."......."."""".".., .....,...,..".",.,..,..,...,..,..,... .. ..".."."........",
<br /> .."..''''''''''''''''''''''''''''
<br />
<br />R e j eet ............".. ,."".'"'''''''''' .....,."",.......,....... ...,..,..,.".""""., ..:..,..,..,...... "''''''''''''''''''''..'''''' ..,...,..,."..,..".,...., ...... ..."."."",.....
<br /> .....,..,...........".."""",.".
<br />
<br />@ PrInted wilh $;Cly Ink 011 rfl;vClilld paper ;.
<br />
<br />Ihereby certif~ this to be a true and correct cop,! of Hie origlfidi
<br />f[J,ed w.lth tile tat~ of r~,:1hrask". ; .
<br />~'I- 7 -' :~t../'<-*ru;r'n....+l../,
<br />.~ .)u') 1, ~ZL:k~~ by
<br />7IV
<br />I "~_l""=__ d (-) y 01 .
<br />
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<br />
<br />~,..;.w:.,,~....
<br />......~'...,..~....
<br />
<br />(:.\~~I~i{)
<br />
<br />~-- -----
<br />
<br />TERRY L. LOSCHEN
<br />MY COMMISSION EXPIRES
<br />May 2, 2006
<br />
<br />
<br />
<br />1 o(7iJ t2.5
<br />
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