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<br />"-".-..... WHEN THIS COpy CARRJES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANI"J:J!i(lfIflf.Hi!;tfVU;ES
<br />SYSTEM. IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL.8ltC.~..(JlM;ILt!,WlTH
<br />. THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM. VITAL STAT~~TlON. -WliicH-'S
<br />
<br />:::;::~:::::~TORY FOR2V10TAOL R7ECOOR1DS6. 7 2 li:iz~: J=.~~~ .:
<br />
<br />neT 1 200" ~ v-u;.N~-eOOP.ER
<br />\u c. As_rANT STA TE REGISTRAR
<br />LINCOLN. NEBRASKA HEAL TH ANDfi!J.W!~~-S,'€8t.gM
<br />STAlE OF NEBRASKA- DEPARTMENTOFHEALrn AND IruMAN SER.~~llT
<br />VITAL STATISTICS -- d""_= - .-
<br />CERTIFICATE OF DEATH
<br />
<br />1. DECEDENT. NAME
<br />
<br />FIIlST
<br />
<br />...'DOlE
<br />
<br />LAST
<br />
<br />2. SEx
<br />
<br />3, D^TEOFOEATH
<br />
<br />
<br />Francis
<br />4. CITY AND STATE OF BIRTH tIIrc/;" V,SA.. _ccuntryl
<br />
<br />Andrew Redler
<br />sa AGE -\..00\ Ill""",,,. UNDER I YEAR
<br />IV...) Sb. MOS. DAYS
<br />-'3 ':L___H
<br />sa. PLACE OF DEATH
<br />
<br />Male
<br />. UNDER 1 DAy
<br />5(:. HOURS I UINS.
<br />,
<br />
<br />Oct 1 2002
<br />6, DATE OF BIRTH _ OIly, YH<1
<br />
<br />Albion, Nebraska
<br />: 7. SOCIAL SECUR11Y NUM!)EA
<br />.
<br />I 508-32-8378
<br />I 81>. FACILITY - Nluno (1/ rei it>slIMIan. g/Yo _ 000 numIlstl
<br />I
<br />j Wedgewood Care Center
<br />6c, CITY, TOWI< OR LOCA nON OF DEATH
<br />
<br />Nov 24 1914
<br />
<br />
<br />HOSPITAL' D "'patio", OTHER 00 Nur!;llf\9 Horn/:!
<br /> D ER~ 0 Residence
<br /> D OOA D 01"'" ISwc"YI
<br />8<f INSIDE CITY LIMITS
<br />
<br />Grand Island
<br />9a, RESIDENCE. STATE
<br />
<br />9d. STRi'ET AND NUM5fR IIncIuJlng Z;P """"I
<br />
<br />--........, 90'. IN~OE. CI'l"Y L1Mn"S
<br />
<br />Nebraska
<br />10, RACE. (..g" White, BI..~, A-'Can !ndlen.
<br />etc.IISpoc"Y1
<br />
<br />68801
<br />
<br />y"OO No D
<br />
<br />(8 offl,. 9""....""" ~.inol
<br />
<br />
<br />FIlST
<br />
<br />M'DDLE
<br />
<br />lAST
<br />
<br />17 MOTHER
<br />
<br />Marian Mohanna
<br />15 EDUCATION (Spoc;fy only '"""'"' ~ compIotodl
<br />~",So<:oroary 10.12)' COIIo{jO 11-40""
<br />12 ' 2
<br />MIDDlE MAlDEN SURNAME
<br />
<br />Andrew
<br />
<br />rtle
<br />
<br />Baile
<br />
<br />203 Wainwri ht st. Grand Island NE 68801
<br /><1). EM6Al.MER. SIGNATURE & LICENSE NO. 21a. 'lrn<<lO OF DlSPOSI1lON 21b. DATE
<br />
<br />21c. CEMUERY OR CREoMAfORY , NAME
<br />
<br />Not Embalmed
<br />
<br />D &lriaI 0 Removal Oct 2, 2002
<br />~ereo-.DOoo.-
<br />719 Front St.
<br />
<br />Central Nebr. Cremation
<br />
<br />220. FUNERAL HOIolE " NAME
<br />
<br />21d, CEMETERY OR CREMATORY lOCATION
<br />
<br />CITY OR 10'Ml
<br />
<br />STATE
<br />
<br />Curran Funeral Cha el
<br />22b. FUNERAl HOOlE I\DDRESS ISffiEET OltR.F.D, NO.. CITY OR TOWN. STATE. 21PI
<br />
<br />Gibbon NE
<br />
<br />3005 South Locust Street
<br />23, ""MEDIATE CAUSE
<br />PART
<br />I
<br />
<br />Grand Island NE 68801
<br />fENTER ONLY ONE CAUSE pER UNE FOR 101. fbl. AND {ell
<br />
<br />InleI'VaI bMWeen onset otl"lCl oe.aUl
<br />
<br />'al
<br />Du"ETif OR />J; A CONSEQUENCE OF,
<br />
<br />Prostatic Cancer
<br />
<br />inteo'val _ onGSt and """'"
<br />
<br />fbl
<br />DUE TO. OR />J; A CONSEOIUENCE OF:
<br />
<br />260.
<br />
<br />2llb. OATE OF INJURY (1./0. Day. Y',I 25<. HOUR OF INJURY
<br />
<br />
<br />1 lnterval between onset and dearn
<br />I
<br />I
<br />I
<br />25. WAS CASE REFEARED TO MEDICAl.
<br />EXAMINER OR CORONER?
<br />
<br />'el
<br />PART OTHER SIGNIFICANT CONOITIONS . CondItIon< conII'lbuting 10 Ill. ",",'" "'" not ,01....,
<br />
<br />.
<br />
<br />o Aceidon' 0 U_1nod
<br />o Suicide 0 Pending 280. INJURY AT WORK
<br />o Ho_ InYOStlg<lOon Y.. 0 No 0
<br />Ill.. DATE Of DEATH (Mo..o.y. y,(
<br />
<br />26g. LOCAnON
<br />
<br />STREET OR R,F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />28a. DATE SIGNEO 11./0.. Day. Y<.I .--....,.-, "2ao:-rlME OF DEATIj
<br />
<br />Cel. T01ho_olmyknowlodgo."'~' 0'
<br /><:atJOO(SI__ .
<br />. __ ,.._ IJ, .,~..,
<br />~D TOOACCO USE CON- .- DEA
<br />DYES
<br />
<br />
<br />October 1, 2002
<br />
<br />M
<br />
<br />- l'i
<br />$[;l
<br />l~~
<br />iP
<br />
<br />"''-<
<br />
<br />>21b. OA IE SIGNED (Mo., o.y Y<.I
<br />
<br />II7e TIME OF DEATH
<br />
<br />2&. PRONOUNCED DEAD 1M" Day. Y'.J
<br />
<br />2M. PRONOuNCED DEAD (lk",,!
<br />
<br />10/02/02
<br />
<br />M
<br />
<br />289. On the basis 0( muvninatk)n anolDl' IlYestiQation, in my opinion dealtl occ!J(red 8.1
<br />...., limo. _ end pIoce """ <Ml1o'" eauoo(.I_.
<br />
<br />808.'WAS CONSENT GRANTED?
<br />o YES NO
<br />
<br />Doctor William.
<br />------
<br />32lL REGlSTAAA
<br />
<br />Lawton
<br />
<br />
<br />Island
<br />
<br />NE 68803
<br />321>. DATE FllED BY REGISTRAR (Mo.. Day, Y'J
<br />
<br />DC] 4 2002
<br />
<br />-,_.~"..
<br />
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