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<br />WHEN THlSCOPYCARR/ES THE RAISED SEAL ,OF THE NEBRASKA HEALTH AND~CES
<br />SYSTEA(" CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL .' . _~~,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAns . .'~
<br />THE LEGAL DEPOSITORY FOR VIT.. :4L RECORDS.. .... 4fj"'_.. =.. ". -. '. . '...., ~~. '-..-=. ~.'.
<br />-'.' ." ~..'c'
<br />
<br />DA TE OF ISSUANCE , 2 00 30 71 21 :f ~' - "h'" = ~ l' ~ ~
<br />MAY 281999 200608 824 ASSlSiAJn;.~=....' ......::.... .1STBItR.'. _PJiB.-E....Ii
<br />LINCOLN, NEBRASKA HEAL TH AND HIlfJIAN . V8TEMf
<br />STATE OF NEBRASKA. DEPARTh1ENT OF REALm AND HUMAN SEA~ANti~S~RT
<br />VITAL STATISTICS ",~.::'- -"" -,""- c:7
<br />CERTIFICATE OF DEATH ~~""-:.--:.:,~-=-'-:'"'
<br />
<br />1. DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH /Month. Day. YUtl
<br />
<br />Ruby
<br />., CITY AND STATE OF 61RTH I"ne/In U.S.A. no",. countryl
<br />Cairo, Nebraska
<br />7, SOCIAl. SECURTIY NUM6ER
<br />
<br />Jane
<br />
<br />Lindsay
<br />
<br />Ss. AGE. L.1l6irthd.V UNDE~ , YEAR
<br />IYrs'82 5b. MOS DAYS
<br />
<br />lis. PLACE OF DEATH
<br />
<br />Female
<br />
<br />May 16, 1999
<br />6. DATE OF 61~TH (!.Iontrl, Day. Ya"l
<br />
<br />
<br />UNDER 1 DAY
<br />5e, HOURS' MINS.
<br />
<br />February 26, 1917
<br />
<br />508-12-0060
<br />Ib, F~I~ITY. NI",. (" not ""1IIution. g1vo._ MId nUlllt>>tI
<br />
<br />st. Francis Medical Center
<br />Ilc, CITY, TOWN OR lOCATION OF DEATH
<br />
<br />HOSPITAL, [Xl Inp.lient OTHE~. 0 Nl,lrSlflQ Home
<br /> 0 ER OutpoUlnl 0 ReSIdence
<br /> 0 DOA 0 Other IS~"'y.1
<br />6cl, INSIDE CITY liMITS
<br />
<br />1 0, ~AC~. II,g" Whitl, 6laek. American MilO, 11, ANCESTRY I..g.. ""lian, MI.iean, Germsn, atel
<br />
<br />""IIS_iM Whi te IS_1M Gennan
<br />
<br />a.. USUAlOCCUPATIQN IGiVOk/J1dolworlt_~""",
<br />alworltintl life, avon" "_1
<br />Teacher
<br />
<br />Grand Island
<br />
<br />lla, ~ESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />18, FATHER. NAME
<br />
<br />
<br />
<br />Shoopman
<br />
<br />ed, STREET AND NUM6ER /lnclvdlng Z;p C_,
<br />
<br />!Ie INSIDE CITY liMITS
<br />
<br />11 YI' 0 No [XI
<br />I" wI/f, IliVO ""'itWn 00""'1
<br />
<br />15. EDUCATION (SpeCify only higl'!tilt grade completed)
<br />EIe",.ntlry Or s.cooO.ry 10-121 CoI"I1' 11.4 or 5"'
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />MIDDLE
<br />
<br />MAIDEN SUFlNAM~
<br />
<br />ii
<br />
<br />Jesse
<br />18. WAS DECEASED oVER IN U,S, ARMED FORCES?
<br />IVes. no. or ur'lk:.l Ilf yes. give wlr and' dales 01 Ni"ViC.'1
<br />No
<br />
<br />Judy Sheeks
<br />ISTREET OR RF,D. NO" CITY DR TOWN. STATE. ZIPI
<br />
<br />19b. INFORMANT
<br />
<br />Lucv
<br />
<br />Elizabeth
<br />
<br />MAILING ADDFlESS
<br />
<br />1924 Freedom Drive
<br />
<br />/2'10
<br />
<br />Grand Island, NE 68803
<br />21.. METHOD OF DISPOSITION 21b. OAT!:
<br />
<br />I 21 e. CEMETERY OR C~EMA 1 ORY . NAME
<br />
<br />
<br />06u",' 0 ~.m",11 5/19/99 Mt. Pleasant Cemetery
<br />210. CEMnERY OR CREMATORY lOCATION CITY O~ TOWN STATE
<br />
<br />o Crem.liOfl 0 Donal'on
<br />
<br />22b, ~UNERAl HOME ADD~ESS
<br />
<br />Apfel Funeral Hone
<br />
<br />ISTREET OR R.F.D. NO. CITY OR TOWN. STATE, ZIP,
<br />
<br />P.o. Box 126
<br />
<br />Cairo, NE
<br />
<br />Wcx:x.l River, NE 68883
<br />IENTER ONLY ONE CAUSE PER LINE FOR lal./bl, AND lell
<br />
<br />_ 23, IMMEDIATE CAUSE
<br />PART (" . I
<br />· I la, V\J /) 0 A\ \.. '{""/\, A-1..
<br />~ DUE TO, OR AS A CONSEOUENCE OF
<br />.
<br />]I
<br />
<br />.:....;.:".-..........,
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />1
<br />I
<br />I
<br />I
<br />I
<br />25, WAS CASE ~EFERRED TO M~DICAL
<br />EXAMINER OR CO~ONE ?
<br />
<br />Interval betwMn onSl!!1 and dealh
<br />
<br />r ...A-~tU
<br />
<br />yyug
<br />
<br />ln1ervat between onset and death
<br />
<br />'!:I_n_ . r._~_
<br />DUE TO:OR AS A CONSEOUENC~ OF.
<br />
<br />Il"\lflrva! t)etween onsel aM deal'"
<br />
<br />/el
<br />PART OTHER SIGNIFICANT CONDITIONS.. Con<!nlons eonlnbuting 10 1he d.ath but flOl rellled
<br />
<br />Ii
<br />
<br />
<br />261.
<br />
<br />o Accident 0 Uncle1ermil"\ed
<br />o SuiCide D Pending
<br />o Homicide Inve$II~Hnion
<br />
<br />261>. DATE OF INJURY lMo., Day., Yt,1 25c:. HOUR OF INJURY
<br />
<br />2641. INJU~Y AT WORK
<br />Ves 0 No 0
<br />
<br />26g. lOCATION
<br />
<br />ST~EoT OR AF.D, NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a. DATE OF DEATH IMO. qay., Y.d
<br />
<br />28.. DATE'810NED lMo" Day.. YU
<br />,coo;: -.
<br />
<br />2ab_T'~u>F D~^ T~_~ . ~
<br />
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<br />
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<br />~n
<br />
<br />28e. On II'Ie ballt of ...aminanon and/or 1n"'81tigatiOR, i" my opinton caath occurred a1
<br />the time. d.te and place ancl due to tht cause{.' etaIed.
<br />
<br />M
<br />
<br />2Ilc. PRONOUNCED DEAD lMo.. Day, Yt.)
<br />
<br />2ad, PRONOUNCED DEAD (HoW
<br />
<br />M
<br />
<br />31, NAME AND ADD~ESS OF CE~T1FIER IPHYSICIAN, C~ONER'S PHYSICIAN OR COUNTY ATTO~NEYI IType Of POnti
<br />
<br />3O.b WAS CONSENT GRANTED?
<br />o YES .8 NO
<br />
<br />David R. Colan M.D.
<br />321, REOIST~A~
<br />
<br />
<br />Grand Island NE 68803
<br />32b, DATE FilED 6Y IAVR !'4,gS9
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