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<br />J
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON RLiiWlfH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TlST~S_SE.CTI,~W#~~_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~...C.i'.... ;;~/:~{,.loloJ'-;. '"H.~'. '~;:'~.':""".~.';.:.~'.'Y.~._\
<br />
<br />DATE OF ISSUANCE _' " jt/;-,~,~ ':
<br />2007055 5 9 . .... "liiiLEY S.~~R -~:
<br />AIIC Q ?nn? ASSiStANt-STATE REGISTRMF:,
<br />lJM!6LN, ilEtllOl~ HEAL TH AND H~N~fIilIJ:;~!.~yjT#f~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEAL rn AND HUMAN SERVk~JNANti: ~~RT
<br />VITAL STATISTICS -~ic;:c-:'=' '-.-~"'---\.. 9 0 0 9
<br />CERTIFICATE OF DEATH -''"=-=:~~~''""~':-~2 0
<br />! I OE:CEDENl -NAMF ~IHSI ~;il'66.CE:'.' l.AST 2 SEX . r,3. D~rEot'oEATH IMonth nail 'r"F!ar.'
<br />
<br />Geraldine
<br />
<br />Margaretha
<br />
<br />Fisher
<br />
<br />Female
<br />
<br />
<br />2002
<br />
<br />4. CITV AND STATE OF BIRTH IffnolinUS./l, namocovntryJ
<br />
<br />Bruning, Nebraska
<br />7 SOCIAL SECuATIV NUMBEH
<br />
<br />5a AGE - La:!;il SIr1hday
<br />IVesl 87
<br />
<br />UNDER 1 YEAR
<br />;-6' MOS I OJ\, vs
<br />I
<br />
<br />UNDER' DAY
<br />5c. HOUAS MINS
<br />
<br />DA TE OF BIA 1 r~ fMonttJ. Vav Y~arJ
<br />
<br />October 6, 1914
<br />
<br />506-14-3100
<br />~CiT'y . Name
<br />
<br />8a Pl ACE OF DEATH
<br />HOSPI r AL
<br />
<br />D Inpatient
<br />D E:.R Outpatient
<br />D DOA
<br />
<br />OTHER
<br />
<br />KJ
<br />D
<br />D
<br />
<br />Residence
<br />
<br />NurSII1g ~iOI"lf'
<br />
<br />{ff nor institution, give slr~el and numb8rj
<br />
<br />Lakeview Nursing/Rehab Center
<br />
<br />Other (SoeCI/~'
<br />
<br />elc.l rSoeofyl
<br />White
<br />
<br />11. ANCESTRY le,g Italian. Mel(lcan. German, elc)
<br />fSpeclfyl
<br />German
<br />
<br />
<br />Hall
<br />STREET AND NUMBER fmc1uaingZlpCoaO! -~----T9f-! IN SID!:: CI"IY LIMITS
<br />
<br />Stuhr Rd. 68801 Vo, [K] No D
<br />13, NAME OF SPOuSE (II ';"(Ifl:.'. givt? malaer) (ldrneJ
<br />
<br />S.C. "Chuck'Fisher
<br />
<br />8c Clly, fOWN Ot=! LOCATION OF DEATH
<br />
<br />8c:f INSIDE CITY !.,IMH S
<br />
<br />COUNTY OJ;: DE-A TH
<br />
<br />Grand Island
<br />
<br />
<br />9, RESIDENCE -ST A I E
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />14a USUAL OCCUPA T10N (Give kind of work done dun'ng most
<br />of wtJrklng lite, even if refired)
<br />Secretary/Editor
<br />16 FA.THER - NAME" F=IRST MIOOt.E=
<br />
<br />15 EDUCATION ISpecl1v only highest grade completed)
<br />. . Elementa~ p[ Secondary 10-12) College /1.4 or ~-I
<br />NE Quarter Horse Assoc1at1 n lL
<br />LAST 17 MOTHER FIRSt M1DDl.F MAlDEN SURNAMf
<br />
<br />John
<br />
<br />
<br />Ada
<br />
<br />Wilhelms
<br />
<br />16 WAS DECEASED EVER IN U's, ARMEO FORCES?
<br />(Yes, no, Of unk.l lit yeS. gIVe war ancl dales 01 servicesl
<br />No
<br />
<br />- NAME-." ~_.""
<br />
<br />19b, INFORMANT
<br />
<br />MAILING ADORESS
<br />
<br />"Chuck" Fisher
<br />ISTREET OR RFO NO.. CITY OR TOWN STATE. ZIPI
<br />
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />~-d12
<br />
<br />21 ii, METHOD OF OISPOSITION 21 b, DATE
<br />
<br />2,c. CEMETERY OR CREMATORv NAME
<br />
<br />[Xl Burial D Removal Au
<br />
<br />
<br />2002 Lutheran Cemetery
<br />CITY OR TOWN STAlL
<br />
<br />A fel-Butler-Geddes
<br />
<br />D CremiilliOfl D Oonallol"
<br />
<br />Bruning, Nebraska
<br />
<br />22b FUNERAL HOME ADDRESS
<br />
<br />ISTREET OR RF.D. NO. CITV ()R TOWN. STATE, ZIPI
<br />
<br />1123 West Second,
<br />. 2J:~:'T'iMMEDIA~~CAUsEHH=> ~ //
<br />
<br />fal ~.?:: /r" r-
<br />DUE TO, OR AS A CONSEQuENCE OF
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />(ENTER ONl Y ONE CAUSE PF:R LINE FOR 131. (bl. ANO (ell
<br />
<br />~"~__VT-;-'- -
<br />
<br />InterVJI bclwoor'l OrIS!::!! ,FI(;
<br />
<br />~ ~./,--4"
<br />
<br />Interval botween onsa, <lr\(; tJblll'
<br />
<br />[bl
<br />-[iuE'l'ciiifiASACc)iisEO'UEiicE OF
<br />
<br />!rlkrV<-II!)i-!IWf!f!nCln!5i'!!,'1'1n i-:t-;;'itr
<br />
<br />o
<br />o
<br />)0
<br />
<br />AC::C:lrl~nt 0 Undetermined
<br />SUICide 0 Pf!nrllnq
<br />
<br />Homicide Investigation
<br />
<br />26e INJURy A I WORK
<br />vesD N()D
<br />
<br />
<br />
<br />
<br />lei
<br />
<br />P'AA 1 OTHER SIGNIFICANT CON/TI?NS - Condill(Jfl$ conlfloutirig 10 lhe dealh but not related
<br />
<br />
<br />II ..LJt'" h- P /I '7 r' ~
<br />
<br />26' 2Gb. DATE OF INJuRv 26c HOUR OF INJURV
<br />
<br />:27a, DATE OF DEATH fMo.. D~y,' Yr.J
<br />
<br />28a, DATE SIGNE.D (MO, DeW Yr,}
<br />
<br />--------128b liME oeD'-ATH
<br />
<br />August 1,2002
<br />27b OA TE SIGNED iMo__ Day "I
<br />
<br />B~
<br />~Q
<br />~f~
<br />E ~ "
<br />8 ~o
<br />H
<br />I !;(
<br />
<br />
<br />~.~ ug ust 2, 2002
<br />
<br />11 : 30
<br />
<br />am
<br />
<br />~..,,: w...
<br />~~~
<br />!~t:~
<br />8~~~
<br />.8~3
<br />,0 Ii' '--'
<br />86
<br />
<br />..~.
<br />
<br />28c. PRONOUNCED DEAD IMo D,y, Yr.I
<br />
<br />280. PRONO~JNU".U DEAD (Hour
<br />
<br />M
<br />
<br />M
<br />
<br />28e, On the basis 01 Qxamlnallon aM Of inv9sllgaliDr"\, In my opiniOn dealh uecur'r'ec! iH
<br />the lime. date and place and due 10 the ci;luse(sl stated
<br />
<br />29
<br />
<br />1St nCilura and Tifle ...
<br />30. HAS ORGAN OR TISSUE OONA TION ~ONSIDERED?
<br />
<br />, D VES ~ NO
<br />
<br />30.0 WAS CONSENT GRANTED',
<br />D VES
<br />
<br />~
<br />
<br />31.
<br />
<br />fTyve or Print!
<br />
<br />Jane McDonald
<br />
<br />M.D.
<br />
<br />800 N.
<br />
<br />Zha Ave
<br />ttIi/
<br />
<br />Island, NE.
<br />
<br />68803
<br />
<br />32, REGISTRAR
<br />
<br />t1J
<br />
<br />32b. DATE FILEO BY REGISTRAR lMo.. D.y. Y'_I
<br />AUG 8 2002
<br />
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