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<br />-- '---'
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE.lllfpJiilTMEN'tO~HEAL TN,
<br />n CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECOIili WV'FiLE wltf(t~.STA TE
<br />DEPARTMENT OF HEALTH, BUREAU OF vnAL STATISTICS, WHICH 1~"iEtMLDEPi:1S.itfiiW FOR
<br />vnAL RECORDS. .~. ~'C_C'~'. .' -o:-o:.~:.;..;:.. ."~"Tf.._. .
<br />
<br />
<br />DAJT.UE NOF2,sSSUA1NgC.g'ES 200 6 0 9 9 G 9 f ( ~STA~ }}fz;;
<br />.~tNg~T.. - REQiRRAR
<br />LINCOLN, NEBRASKA NEBRASq.tJ!F(4MlHNTtiF.iiEAL TH
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF'HEAL IH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />" "~a~-__~T
<br />
<br />uNDER. , l)A y
<br />5c. HOURS" ..... MINS
<br />
<br />[)A' (("'Or W:'A I H
<br />
<br />r'('c)f'
<br />
<br />I' O"ClD"NINii;~rnard "HSl
<br />
<br />
<br />f4" ciTY AND STATE Of- mATH (If noi-ifi"'iJs A. name covn/ryl
<br />
<br />iM()I1f1~ na~
<br />
<br />MtDOL. E
<br />
<br />LAST
<br />
<br />Joseph
<br />
<br />Crick
<br />
<br />June 13, 1996
<br />
<br />-6.~D^TE-OF BiRTH IMonth U.:Jv 'r"!-'<lrl
<br />
<br />~-' Last 6ir1hda.v UNDER 1 Y(AH
<br />1__:' 73 '0 MOS I DAYS
<br />
<br />. .' --.- -- 6_ PLAC~ OF""DEA T H
<br />
<br />November 12, 1922
<br />
<br />Grand Island, Nebraska
<br />
<br />~ , SOCIAL S~CURTIY NUMBE~
<br />~ 507-14-1539
<br />
<br />100 FACILITY": Name (If not institution, give streef and flumtJer)
<br />'{ Mary Lanning Memorial Hospital
<br />_ ac----crfv. TOWN OR LOCATION OF DEATH
<br />
<br />HOSPIT AL [R] Inpabenl OTHER
<br /> D ER Outpatient
<br /> D DOA
<br />
<br />D
<br />D
<br />D
<br />
<br />NurSing HOfl1!!
<br />
<br />Aesldcr"lce
<br />
<br />Other ISve(:lfV!
<br />
<br />Hllslfngs
<br />9_ RESID~NCE. STATE
<br />
<br />
<br />MAIDEN SURNAM~
<br />
<br />6<1. INSIDE CITY L1MITS.~. "" COUNTY OF DEATH
<br />
<br />Yos ~ No D Adams
<br />9c. CITY. TOWN OR LOCATION ~- 9d StREfT A.IIlD N\.AlI5E:R (1ncludingZip CDdl,'j
<br />
<br />
<br />Nebraska
<br />
<br />,~ 1 9c INSIDE CITY LIMITS
<br />
<br />I Yas [K] NoD
<br />.,." -
<br />Ifl Wife, gIVe malChM name)
<br />
<br />, 3 NAME OF SPOUSE
<br />
<br />"WRiftl
<br />
<br />11 ANCESTRY le.9.. Italian. Mexican, German, eti;l
<br />
<br />'~~~rican
<br />
<br />Ilene M. Bigger
<br />
<br />15. t::DUCA liON (SpeCIfy only t'ughesl grade completed)
<br />Elernenr~ or Secondary 10-121 College (1.4 Of j'l
<br />
<br />l".a USUAL OCCUPA liON (Give kiM 01 worl; done during most
<br />of worlf;ing life. even II rsrifBOJ
<br />Owner/Operator
<br />
<br />~ lG. FATH~R. NAME FIRST
<br />
<br />.~ Edmund
<br />
<br />. 18. WAS DECEASED FV~R IN U.S. ARMED FORC~S?
<br />
<br />IY"V~~' unkl 'W~g;jd-W ;~.il"fViC"'1
<br />
<br />191>. INFORMANT MAILING ADDR~SS
<br />
<br />il
<br />
<br />Grocery Store
<br />LAST
<br />
<br />17 MOTHER
<br />
<br />MIDDLE
<br />
<br />
<br />M'DDL~
<br />
<br />Agnes
<br />
<br />Goff
<br />
<br />Crick
<br />02/02/1943--
<br />12/13/1945
<br />
<br />NAME
<br />
<br />Ilene Crick
<br />
<br />'STREET OR RF D NO. CITY OR TOWN. STAT~. ZIPI
<br />
<br />304 W. 15th St., Grand Island, Nebraska 68801
<br />
<br />
<br />210 METHODOFDISPOSITION 2'0. DATE
<br />
<br />21< CEMETERY OR CREMATORY NAME
<br />
<br />111174
<br />
<br />06/17/1996
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />~8urial
<br />
<br />D Aemoval
<br />
<br />2' O. CEMETERY OR CREMATORY LOCA TlON"
<br />
<br />CITY O~ 'OWN
<br />
<br />STATE
<br />
<br />D Cremation D Oonalll)fl
<br />
<br />Grand Island, Nebraska
<br />
<br />Apfel-Butler.Geddes Funeral Home
<br />
<br />22b FUNERAL HOME ADDRESS
<br />
<br />(STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIPI
<br />
<br />.!II
<br />.~..
<br />..
<br />.,.
<br />~..I
<br />
<br />lIB West Second Grand Island, Nebraska, 68801-5899
<br />23. 'MMEDlA T~ CAUSE IENT~R ONLY ONE CAUSE PER LINE FOR lal. 101, AND 1<11
<br />PART
<br />'ralmultiple System failure (respiratory, renal, heartl.
<br />DU~ TO, OR AS A CONSEOU~NCE OF
<br />
<br />Inlefval between onsel and death
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />1
<br />
<br />: 2 .::-_ 3 days
<br />25 WAS CASE REF~RRED TO MEDICAL
<br />I;XAMINER OR CORONER?
<br />
<br />Interval between on!i8t and Oeath
<br />
<br />4 hours
<br />
<br />1 - 2 days
<br />
<br />(01 sept; cemi a
<br />Df1-s~ff(tDtfi8.'ft~~N1]fFinary tract infection
<br />
<br />~Staphanreus pneumonia _
<br />FJMn OTH~R SIGNIFICANT CONOITIONS - CondlMflS contrlbuting to the death but not relaled
<br />"
<br />
<br />lnlefV'al between onset aM dealh
<br />
<br />
<br />26_
<br />0 ACCident 0 Undetermined
<br />0 SUICide 0 Pending
<br />0 Hornictde Inve$tlgahon
<br />
<br />261>. DATE OF INJURY IMe.. Doy, Y(,} 26<. HOUR OF INJURY
<br />
<br />M
<br />~I. ~;~~n;J~.Y i~ff!l'arm. slreet. lactof)l
<br />
<br />26g. LOCATION
<br />
<br />STREET OR RF D. NO
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />26e. INJURY AT WORK
<br />Y.. D NO D
<br />
<br />270 DATE DF DEATH IMo.. Day. YO
<br />
<br />28,;. DATE SfGNED IMo. Day y,j
<br />
<br />280 TfME OF DEATH
<br />
<br />'-.. I;~
<br />.!! H >-
<br />-~ !iEg
<br />"4 ~i
<br />_il ..
<br />:;)
<br />
<br />June 13,
<br />
<br />M
<br />
<br />
<br />z ~
<br />li'd~
<br />ilU'iZ
<br />Ii ~,~
<br />.s~d
<br />!:w~
<br />.0 ~ 8
<br />~ ,..,
<br />
<br />27b, DATE SIGNED (A.f(J" Day, yf.)
<br />
<br />28, PRONOUNCED DEAD (Mo.. Day, YU
<br />
<br />26<1 PAONOUNC~D DEAD IHoo,'
<br />
<br />12:03 P. M.
<br />
<br />M
<br />
<br />M
<br />
<br />26e On the oasis 01 eX(lmlnallon and, or inve!iitigatloo, In my opinion dealh occurred at
<br />the tl"'9, dale and place and due 10 the causelsl $t.ated.
<br />
<br />270
<br />
<br />30.0 WAS CONSENT GRANTED?
<br />DYES
<br />
<br />KJ NO
<br />
<br />D uNKNOWN
<br />
<br />[K] NO
<br />
<br />31 NAME 'AND A'oDRESS OF CERtiFIER /PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY A110RNEYf frype"O,- PwJ(!
<br />
<br />Dr. John VanMetre
<br />32. REGISTRAR
<br />
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