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<br />94 <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HE~ AND.HiiiMN SERVICES <br />SYSTEM, IT CERTlFIES THE BELOW TO B.E A TRUE COPY OF THE OfJ/(JItli.j;.#E~.:i>it:fILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VlTM;S~S~NFWHICH IS <br /> <br />:::~::~:::::~TORY FOR VITAL RECORDS. ~~i~jM~H;{\fI;,~ <br />NOV 1 91998 20070 2 611 ::~-cj~S:::~':::il~~:: <br /> <br />LINCOLN, NEBRASKA HEAL TH''ANri.iIii(iwI~ti~~~- SYSTEM <br /> <br />STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMAN.~UYICES~E AND SUPPORT <br />VITAL STATISTICS - ""=""'=- -. <br />CERllFICA TE OF DEATH <br /> <br />1, DECEDI::NT - NAME; <br /> <br />F=1F=lST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />3 DAlE OF DEATH IMontfl. Oa't, Year) <br /> <br />Albia, Iowa <br />7. SOCIAL SECURlIY NuMBER <br /> <br />Sa. AGE - Last Birthday <br />IY".I 72 <br /> <br />UNDER 1 YEAR <br />5b. MOS DAYS <br /> <br />Female <br />UNDER' DAY <br />5c. HOURS I t.,4INS <br /> <br /> <br />November 5, 1998 <br />6. DATE OF BIRTH (Month. OilY Year) <br /> <br />Einily Louise <br />4. Cllv AND Sf ATE. OF BIRTH IIf not'" uS,A. name COI.mlryl <br /> <br />Niemann <br /> <br />March 28,.1926 <br /> <br />Bb. FACILITY. Name <br /> <br />(If f'lQt mstirution. give street arid r1umbBr) <br /> <br /> aa. PLACE OF DEATH <br /> HOSPITAL. ~Inp.atient OTHER D Nursing Home <br /> D EA Outpatient D Ae$lc:lence <br /> D DOA D "'her (SVf!C11y1 <br />&d. INSIDE CITY LIMITS <br /> <br />. 482-20-0033 <br /> <br />. St. Francis Medical Center <br />6c. CITY. TOWN OR LOCATION OF DEATH <br /> <br /> <br />Grand Island <br />go RESIDENCE. STATE <br /> <br />Hall <br />STREET AND NUMBER (1m;luding Z,p Coo" <br /> <br />ge INSIDE CITY LIMITS <br /> <br />Nebraska <br />1 O. RACE. (e.g.. White. Black, American lndian. <br />..eIISpecllyl <br />White <br /> <br />68803 <br /> <br />Yes lXJ No D <br /> <br />11, ANCESTRY (e.g" Italian, Me:.m;,an, German. &tcl <br />ISpee11yJ <br /> <br />LAST <br /> <br />17 MOTHER <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />'Pili th <br /> <br />NMT <br /> <br />r.mn!': <br /> <br />1a TH <br /> <br /> <br />21c CEMETERY O~ CHE.MATORv NAMF <br /> <br />Qeunal <br /> <br />l..aw< Memorial Park Cemet <br />CITv OR TOWN STATE <br /> <br />Hane <br />(STREET OR R.F.D. NO CITY OR TOWN. STATE, liP) <br /> <br />D Cremation D Donahor"l <br /> <br />Grand Island. Nebraska <br /> <br />32 3 W. North Front st.. Grand Island, Nebraska 68803 <br />(ENTER ONLY ONE CAUSE PER LINE FOR ral. Ibl, AND lell <br /> <br /> <br />Inlerva! belween onsel and deiiltl <br /> <br />(!}1A..e ~ <br /> <br />lnlefval between onset (lnd dealt... <br /> <br />,< M.dS <br /> <br />Interval between On~l:!1 ana death <br /> <br /> 2lC> 26b DATE OF INJuRY {Mo," Day, Yr.} 26<. HOuR OF INJURY <br /> 0 AcCident 0 UMelermmed <br /> 0 SUicide 0 Pendmq 26. INJuRY AT WORK <br />) 0 Homicide InveSlu:;IallOr\ vesD NoD <br /> <br /> <br />lei <br />OTHER SIGNIFI N ONDITIONS . Conditions conlributing to the ceath but not relaled <br />PARl ,. L> ^ <br />II L-- c:; r I..J <br /> <br />26g. LOCA liON <br /> <br />STREET OR i=l.F.O. NO. <br /> <br />CITY OR TOWN <br /> <br />SlATE <br /> <br />288 OATE SIGNED (MC.. Da,v. 'If! <br /> <br />2ab TIME OF DEA1"'H <br /> <br />z>- <br />,,~ ~ <br />hg>- <br />8"'~l <br />1!~=> <br />"'l58 <br />'-' " <br /> <br />M <br /> <br />26c. PRONOUNCED DEAD (Mo.. Day. Yt) <br /> <br />28d. PRONOUNc~n DEAO (HOwl <br /> <br />,M <br /> <br />M <br /> <br />28e, On the basis of examlnallOn and'or in'w'Etstigation. in my opinion death occurred al <br />the luTle, date ancl place and due to the causal!;) stated. <br /> <br />WAS CONSENT GRANTEO? <br />DYES <br /> <br />.ro NO <br /> <br />Richard M. Fruehlin <br />32a, REGISTRAR <br /> <br />NE 68803 <br /> <br />32b DATE FILED BY REGISTRb~t t.1f 1998 <br />