|
<br />'" . H .,,'.,'..1,.'.,
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A~s~d,
<br />SYSTEM, ITCERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL,~RF~TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATll!1I-~~$ECf1(jN,WIil/PflS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~;.:~_;-""-" 'C . ",,:q- -~
<br />
<br />DATfiOFISSUANCE 200707795 / ~~1311(~
<br />
<br />DEe 2 2 2000 1 Assl$]'A;q~rrxlJleGI' -...,
<br />LINCOLN, NEBRASKA HEAL TH AND HI1MAN - . ,
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALtH AND HUMAN Sl!~VIGE _ PORT
<br />VITAL STATISTICS - - ~-- -,,-
<br />CERTIFICATE OF DEATH
<br />
<br />..-'.. ,. -~..~~._-
<br />.--.- -. -~~-"-
<br />
<br />" DECEDENT - NAMl
<br />
<br />FIASl
<br />
<br />---.~il(;f)l~._---
<br />
<br />LAST
<br />
<br />2 St,X
<br />
<br />-J'.~DAlE OF- Dt::ATH IMon/f1. Dav YBdri
<br />
<br />Duane
<br />
<br />Warren
<br />
<br />Rouse
<br />
<br />/
<br />Male-
<br />
<br />
<br />December 15, 2000
<br />
<br />AIda, Nebraska
<br />
<br />53 AGt: :.L~.-Bi'~i,(ilY ---' '.'"lJN'DER"] YEAR
<br />(Y(S,I 74 So MOS: DAY~
<br />
<br />6 DATE OF BIRTH {Month, Day, y'ear}
<br />
<br />4. CITY AND STATE OF BIRTH (lfnatin USA nameco{Jn(ry}
<br />
<br />:-1(:
<br />
<br />August 10, 1926
<br />
<br />7 SOCIAL SE<5u'RT"iv NLJMH[~
<br />
<br />506-26-2298
<br />
<br />83 PlACE OF DEATH
<br />HOSPIT Al
<br />
<br />D lnpalleflt
<br />
<br />[Z] ER Oulpalierll
<br />
<br />D UOA
<br />A~ COuNlv O!-".O"E'ATH'.
<br />
<br />OlH!::R D NurSing HClmf!
<br />
<br />D Resldoncc
<br />
<br />D O1he! (SJ]OC1fl'l
<br />
<br />(If nof Institution. give street '~;~j "umber)
<br />
<br />So, fACILITY. Name
<br />
<br />St. Francis Medical Center
<br />
<br />6t CITY, TOWN ORLOCA1IDN or DEATH
<br />
<br />8n INSIDE CITY LIMITS
<br />
<br />Gcand Island
<br />
<br />'0
<br />
<br />Y., n<:i '1" n ' H-'1.1-1
<br />
<br />C-6UNTY ~._. 9c g~;:;~~~ATION_=..__J~'~~~ET~N.D N~:~~I:I~':9Z'~C~~. 6883 -,; ~::'D~fYN~jM~
<br />
<br />11. ANCt:.ST HY Ie 9 , Italian, Me)(ICilon, German, elcl 12, [] MARRIEo [] WloOwED 1 J NAME OF SPOuS[ (If wdt', 9,ve mai(1t~n {lameJ
<br />
<br />."'15pec'fyl White ISDec<fyl Amecican... D ~~~~EJ DivORCED Doris M. Eh_~=:_s_________
<br />
<br />14(1 USUAl. OCCUPATION IG!vt:- kind of wol'k done during most 14b KINO or BUSINESS INOUSTRY 15 EDUCATION lSpe(:lly only highest grade (:.~~P~~..!..c:.~J.,..,_..._._.._,...
<br />OIM~h~gen~tO'lredJ Fertilizer Plant Elemcfllarl;2secondafY 10..121 ('flleg~ 11.t\or~).1
<br />
<br />16 FA rHEA _ NAME FIRST MIDDLE L.AST 17 M()THI:::A .._.~-_.'._.FiRS.T ..4", .,.,_. MIDDLE MAIDEN SURNAME
<br />
<br />: ~~, R~m"""fNCE'~"'Al~.-
<br />
<br />
<br />Nebraska
<br />
<br />Warren
<br />:~~ItI,S DECEAS-EDEVER IN US ARMED FORCES?
<br />
<br />IYy ;;~':""' I IIf 'i 'C 3~4:'i'944/'5- 7.-1946
<br />
<br />'9b. INFORMANT MAILING ADDRESS ISTREET OR RF D NO
<br />
<br />
<br />~~t:)'
<br />
<br />Weinrich
<br />
<br />rJAMI::.
<br />
<br />Doris M. Rouse
<br />
<br />202 W. vJalnut,
<br />
<br />P .0_ Box 302,
<br />
<br />Doniphan, Nebcaska
<br />
<br />68832
<br />
<br />
<br />E ALMER - SIGNATURE & LICENSE NO 9 31(
<br />
<br />0' ~~k:Y7""'-<TVoJ (()4lJ1k ~ . _ _."
<br />f-UNEAAL H(jif"~NAME
<br />Apfel-Butlec-Geddes
<br />
<br />21 i~METHOO OF DISPOSITION
<br />
<br />KJ Burial [J Rl~ml)\!JI
<br />
<br />2'b OATF I 2,c CEMETERY OR CREMATORY NAMF
<br />~~?_: __19, ?g,?gJ Cedac View Cemetecy
<br />?1 d CF-ME:T~RY OH (;Hl::MA! ORy LOCATION CITY OR TOWN Sl A I t
<br />
<br />D Cremation D [\()f1i!.11{)r'
<br />
<br />Doniphan, Nebraska
<br />
<br />220 FuNERAL HOME ADDRESS
<br />
<br />{STREET OR RF,D NO CITY OR TOWN. STATE, ZIPI
<br />
<br />1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />23 '"'IM'MEDIATE CAuSE IENTER ONLY ONE CAUSE PFR LINE mR'I~II';'I,ANDICiI--
<br />PARr /'I. ._
<br />~ lal S u.&'J W ~'4 t... /J (AJJL.__.
<br />~ OllF TO, OR AS A CONSEOUENCE Of
<br />
<br />; {bit/it WIA t.M 11 fA/( r ,tJr I tAf l
<br />
<br />DuE TO, OR AS A CONSEOuENCE OF
<br />
<br />Interval between onset and de"m
<br />
<br />";;,, //1.1
<br />
<br />Inlerv.;I1 between on5~1 aM r1~;:!tI\
<br />
<br />~l/(J__m
<br />
<br />hM.4rval 'Jt.lllfitl€f'l ur"lse! ;3f1(1 r1e;'ltr.,
<br />
<br />27a DA rE OF DEA TH"-iMo" Day, Yr-!
<br />
<br />
<br />(Age~ 1 O.~4) Yes
<br />26" HOuR OF INJURy M L~ DEseRI:F :OW IN IlJ"yell ,.u~~~ " .
<br />
<br />
<br />PLACE OF INJURY At home. farm 5lreAl f~(:lory 2Gq, lOCAnON STRE:E:.'J OH H,":.lJ NO.
<br />office budding, ele. (SpeCIfy)
<br />
<br />
<br />I
<br />I
<br />I ._.,..
<br />:2'5, WAS CASE REF=EHRED TO MEDiCAL
<br />EXAMINER OR CORONER'
<br />
<br />Yes n NoJlj_______
<br />
<br />1<1
<br />PART OTHER SIGNIFICANT' CONDITIONS - Conditions contributing 10 the death bUI not relaled
<br />
<br />" ..::t::'" (.N, ~ ( f.. A. r I? ( ftASi
<br />
<br />No
<br />
<br />2", 26b DATE OF INJURY
<br />0 AccIdent [] UMOI€rmined
<br />0 SuiCide 0 Pencilng 26e. INJURY AT WORK
<br />0 Homicide Investlgi:ltlon yesD NoD
<br />
<br />CITy OR TOWN STAr::
<br />
<br />?8;:i nATE"SII3NE:l) (Mo" Dav Yr)
<br />
<br />26h TIMe Of DlAI H
<br />
<br />!_z It---/S--C/D
<br />
<br />i ~ ~ 27b. DATE SIGNED (Mo Day. Yr.) TIME OF DEATH
<br />~!p
<br />:18 ~iS / ~
<br />i ~ ~ >7d
<br />t ,... ~ C(1)Sels) stated.
<br />
<br />i 51 natl,Jre and title) ..
<br />29 DID TOBACCO uS, CON~UTE T
<br />
<br />D YES ~ NO
<br />
<br />31 NAME AND ADDAE:SS OF CERTIFIER (PHYSICIAN, cOR~sTclAr::toHc~6UNTY A TTORNFY I " TVf)e or Print)
<br />
<br />
<br />"-~~ ~
<br />~~g>-
<br />~~; z
<br />U II ~'~ 0
<br />~~~
<br />",~8
<br />;3 =,
<br />
<br />M
<br />
<br />2BC PRONOUNCED DEAD (Mo Day. Yr'.)
<br />
<br />2Bd. PRONOuNCED DEAD (Hout'i
<br />
<br />'M
<br />
<br />M
<br />
<br />28e Onlhe basis of e~amln(lllOn and Or' investigation, in my opinion elealh occurred al
<br />Ihe IHT\8. elale aM place and due 10 the (:au5sls'l staled.
<br />
<br />~-,~~_.,
<br />30,0 WAS CONSENT GRANTED'
<br />
<br />DYES
<br />
<br />_RNO
<br />
<br />David R. Colan M.D. 729 N. Custer,
<br />
<br />'"""'~~~ ~ j~ ---
<br />
<br />Gcand Island, NE.
<br />
<br />68803
<br />
<br />j l?b -6AT"EFTL~O av REGISTRAR (Mo.. V.v, YrJ
<br />DEe 2 1 2000
<br />
|