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<br />WHEN 1HI$ COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM,", CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAfRECORD ON FILE WITH
<br />rHENEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STAnST.--W't1iil41ff1ICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,'., , ,_:-=~"::~-#~-'"
<br />
<br />DATEOFmwANCE ~~
<br />LI;!o~:~E~~S~ 20 0 8 0 3 6 6 3 HEALtH A=~~". .,': ,~fM'
<br />
<br />STATE OFNEBRASKA-DEPARThfENT OF=~A~TI~r'~-cn;;i: .1- :,~~~RT
<br />CERTIFICATE OF DEAnf;~::i3;::,~_~k:?ii~-' 03 10539
<br />2. SEX 9 ,~1:~
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />1, DECEDENT. NAME
<br />
<br />
<br />73
<br />
<br />UNDER 1 YEAR
<br />5b, MOS, I DAYS
<br />I
<br />
<br />
<br />2003
<br />
<br />Donna
<br />
<br />Arlene
<br />
<br />Knuth
<br />
<br />Grand Island, Nebraska
<br />
<br />oa. AGE - Last airthday
<br />IYrs,1
<br />
<br />6, DATE OF alRTH (Month, Day, Year}
<br />February 9, 1930
<br />
<br />4, CITY AND STATE OF elRTH (If net in U.S.A.. name country}
<br />
<br />Bb. FACILITY - Name
<br />
<br />(If notinstitutiOn, give stt'eet and numb8r)
<br />
<br />80. PLACE OF DEATH
<br />HOSPITAL: 00 Inpatient
<br />o ER Outpatient
<br />o DOA
<br />
<br />OTH'="'-, 0 Nursing Home
<br /> D Residence
<br /> 0 Olher ISplE/cdYI
<br />
<br />7, SOCIAL SECURTIY NUMBER
<br />
<br />508-30-7786
<br />
<br />St. Francis Medical Center
<br />
<br />Nebraska
<br />
<br />
<br />8d, INSIDE CITY LIMITS Be, COUNTY OF DEATH
<br />
<br />8e, CITY. TOWN OR LOCATION OF EATH
<br />.'Grand Island, Nebraska
<br />
<br />Hall'
<br />
<br />Hall
<br />
<br />9d, STREET AND NUMBER (Includ(ng Zip Codel ge, iNSIDE CITY LIMITS
<br />
<br />Yas ~ NO D
<br />13. NAME OF SPOUSE (If wife. give maiden name}
<br />
<br />9a, RESIDENCE. STATE
<br />
<br />1 D. AACE - (e,g., White, Black. Americiln Indian.
<br />ote.IISpoelty) Wh i t e
<br />
<br />American
<br />
<br />Howard J. Knuth
<br />
<br />
<br />MIDDLE
<br />
<br />Own Home
<br />LAST
<br />
<br />15, EDUCATION (Specify only hi~heS1 grade completed)
<br />Elementary or Secondary (0.121 1: 2 College" (1-4 Or ~....)
<br />
<br />14i!. USUAL OCCl,JPA TION (Give kind of WQrk done dI.lf'ing mast
<br />01 working life, 8ven il retired)
<br />Homemaker
<br />
<br />J. Knuth
<br />ISTREET OR R.F.D, NO.. CITY OR TOWN. STATE, ZIPI
<br />
<br />
<br />Marie
<br />
<br />(NMI)
<br />
<br />Mathews
<br />
<br />FIRST
<br />
<br />17, MOTHER
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />(NMI)
<br />
<br />Pahl
<br />
<br />Grand Island, Nebraska 68801
<br />210. METHOD OF DISPOSITION 2'b, DATE 21<. CEMETERY OR CREMATORY - NAME
<br />Septmber 15, Unive~sity of NE
<br />o Burio' DR.movol 2003 Anatomical Board
<br />21d, CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Funeral Home DC,.mat;on IXJDon..,on Omaha, Nebraska
<br />
<br />22~, FUNERAL HOME ADDR~SS
<br />
<br />ISTREET OR R,F.D, NO., CITY OR TOWN, STATE, ZIP)
<br />
<br />3213 W North Front Street, Grand Island, Nebraska 68803
<br />
<br />,ENTER ONLY ONE CAUSE PER LINE FOR 101,1~I, AND lell
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />)/;, WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />Int~Hval between onset and death
<br />
<br />23, IMMEDIATE CAUSE
<br />P~,,*
<br />lal
<br />"DUE TO, OR AS A CONSEOUENqE OF'
<br />
<br />Interval batwaen onset and death
<br />
<br />ARDS
<br />
<br />72 HRS
<br />
<br />Ibl CHF PNEUMONIA
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />72 HRS
<br />
<br />Interval between onsel and dealn
<br />
<br />lei
<br />PA~r OTHER SIGNIFICANT CONDITIONS. Conditions contributing 10 tne dea.th but not related
<br />
<br />II
<br />
<br />CAD
<br />
<br />OM
<br />
<br />20 VRS
<br />
<br />
<br />26a,
<br />
<br />26b, DATE OF INJURY (Ma.. Day, Yr.} 26c, HOUR OF INJURY
<br />
<br />Accident 0 Undmermined
<br />Suicide 0 Pending
<br />
<br />Homicide
<br />
<br />Investigation
<br />
<br />260. INJURY AT WORK
<br />vesO NOD
<br />
<br />289. LOCATION
<br />
<br />STREET OR R,F,D, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />280. DATE SIGNED (MO.. Day Yr.)
<br />
<br />28b, TIME OF DEATH
<br />
<br />AM
<br />
<br />$~O:;
<br />hL
<br />8~~~
<br />~~o
<br />~8~
<br />
<br />M
<br />
<br />26c, PRONOUNCED DEAD (Mo.. Day, Yr,)
<br />
<br />28d, PRONOUNCED DEAD (Hovr)
<br />
<br />M
<br />
<br />28e_ On tne ba;$I$ of examination and/or investigation, in my opinion dealh OC(lI,u'ted at
<br />the time, date and place and dUB to the cause(s) stated.
<br />
<br />3J(' WAS CONSENT GRANTED?
<br />
<br />[X] YES 0 NO
<br />
<br />GRAND SLAND NE 68803
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.}
<br />
<br />SEP 1 9 2003
<br />
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