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<br />-.'
<br />
<br />WHEN THIS Copy CARRIES THE RAISED SE~L OF THE NEBRASKA HE~L TH ~NDcffUM.AN.SERVlCES
<br />SYSTEM, "CERTIFIES THE BELOW TO BE ~ mUE COPY OF THE ORIGIN~U~ECORD ofiFfL.-fWlTH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA Tl$tICSSECTifi;t,=WifiCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.."':."." _:..,. .-' . 'g=-. ,=c:,.~.=...~..,,".:~:c
<br />
<br />D,IO...e OF 'SSU'IONCE .... - '. - .~
<br />J't, a;; " ,.. . - - 1- - . ~~ ~-'~
<br />
<br />5/14/2003 200509843 :' '. '. " ifNLEy~COOPi!R
<br />ASsiSTANT STA TE REGisiRAR
<br />HEALTH ANii)iUilAN'~~$-~~J!!M
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA- DEPARlMENT OF HEALTH AND HUMAN SERVfh:s FiNAN~;:gupPORT
<br />
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />Carol
<br />4. CITY AND STATE OF BIRTH IIf not in U.S.A.. name country)
<br />
<br />Ann
<br />
<br />
<br />ht
<br />UNDER' YEAR
<br />MOS. I DAYS
<br />I
<br />
<br />
<br />03
<br />
<br />05357
<br />
<br />,. DECEDENT" NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />(MOnth. Opy. Ye~rl
<br />
<br />9 2003
<br />(Month. Day. Year)
<br />
<br />Sumner Nebraska
<br />: 7. SOCIAL SECURTIY NUMBER
<br />
<br />: 505-70-9681
<br />
<br />: 8b" FACILITY ~ Name (If not institution. givs strBtH and numbBrJ
<br />
<br />. Saint Francis Skilled Care
<br />I
<br />_ 8c . CITTf6wN OR LOCATION OfOEA TH
<br />
<br />3 1951
<br />
<br />6..
<br />
<br />HO~PI.!~
<br />
<br />D Inpatient OTHER: D Nursing Home
<br />D E.R QUlpatlenl D ReSidence
<br />D DOA 00 Oth9( (Specdv! Skilled Care
<br />COUNTY OF' DEATH'
<br />
<br />I
<br />
<br />14a. USUAL OCCUPATION IGille kind of work done during mosf
<br />01 workmg lile. even jf rellred)
<br />Child Care Provider
<br />
<br />14b.
<br />
<br />
<br />9d. STREET AND NUMSER (Including Zip Codel
<br />
<br />ge. INSIDE CITY LIMITS
<br />
<br />Grand Island
<br />
<br />1 O. RACE - (e.g.. White. Black:. American Indian.
<br />elc,IISpeclfyl Whi te
<br />
<br />
<br />11, ANCESTRY le,g.. Italian. Mexican, German, etcl
<br />(Speclfyl
<br />
<br />68801 yesOCJ NoD
<br />13, NAME OF SPOuSE Ilf Wife. glV9 maid8f1 nam8)
<br />
<br />90. RESIDENCE" STATE
<br />Nebraska
<br />
<br />American
<br />
<br />i 16, FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />Child
<br />LAST
<br />
<br />Frank A. Wright
<br />
<br />15. E:OUCATION (Specify only highest grade r.:ompleted)
<br />Elementary or Secondary 10-12) COllege (1-4 Or :)~\
<br />12
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Merl Otto
<br />- 1 B. WAS D~CIOASED EVER IN U.S. ARMED FORCES?
<br />(Yes. nO. or unk.) (If yes. give war ancl dates of servicesl
<br />No
<br />
<br />vir inia
<br />
<br />Lovett
<br />
<br />Frank Wright
<br />
<br />1 BO. INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN, STAT~, ZIP)
<br />
<br />403 E. Dodge St., Grand Island, Nebraska
<br />
<br />00 Burial D Flemoval
<br />
<br />
<br />68801
<br />
<br />
<br />20, EMBALMER.. SIGNATU
<br />
<br />D p(-,,/
<br />
<br />"\
<br />'1071
<br />
<br />21a, METHOD OF DISPOSITION 21b. DATE
<br />
<br />STATE
<br />
<br />All Faiths Funeral Home
<br />
<br />D Cremation D Donal:on
<br />
<br />Grand Island, Nebraska
<br />
<br />22b, FUNERAL HOME ADDRESS
<br />
<br />(STREET OR R,F,D, NO, CITY OR TOWN, STATE. ZIP)
<br />
<br />2929 S. Locust St.,
<br />
<br />Grand Island, Nebraska
<br />b/'i IENTER ONLY ONE CAUSE P~R LINE FOR lal, [bl, AND (ell
<br />/.,)VOl Jl ~ LaA..r CP/l.../
<br />
<br />68801
<br />
<br />26a.
<br />
<br />2Gb. DATE OF INJURY (Mo.. Day. Yr.) 2Bc. HOUR OF INJURY
<br />
<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 />25, WAS CASE RE;FERREO TO MEDICAL
<br />EXAMINER OR CORONER'
<br />
<br />Interval between onset and death
<br />
<br />23. PART IMMEDIATEf~:U~Eiu' '. ~Jh\
<br />I ,'V\...L L S Ie..
<br />I lal
<br />:; DUE TO. OR AS A CONSeQUENCE OF
<br />
<br />Ibl
<br />DUE TO, OR AS A CONSmUENCE OF'
<br />
<br />Interval between onset and death
<br />
<br />fo )..4 cJ~
<br />
<br />Interval between onset aM deatl1
<br />
<br />101
<br />
<br />OTHER SIGNIFICANT CONDITIONS - C()'idition5 contributing 10 the death but not related
<br />PART C.. I
<br />
<br />II -:::;,€ $LS
<br />
<br />D
<br />D
<br />D
<br />
<br />Acou:lenl 0 undetermined
<br />Suioide 0 Pending
<br />
<br />Homicide
<br />
<br />Investigation
<br />
<br />26.. INJURY ATWORK
<br />Yes D No D
<br />
<br />26g. LOCATION
<br />
<br />STREeT OR R.F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a, DATE OF DEATH (Mon OilY. Yr,)
<br />
<br />26a. DATE SIGNED (Mo.. Dav. V,.!
<br />
<br />2Bb TIME OF DEATH
<br />
<br />May
<br />
<br />9 ,
<br />
<br />2003
<br />
<br />M
<br />
<br />- -'"
<br />HL
<br />: !iE ~
<br />- .~
<br />-H
<br />~..
<br />
<br />$a ~
<br />II >- i!i 28c. PRONOUNCED DeAD IMo.. Dav, y,.!
<br />ia:~~
<br />l';l,)OO3' 2;45 A. M ~g~e
<br />
<br />27d. To the best of my know,ledge. death occurred at the time. date aM place and due 10 tne ~ ~ ~ 288. On Ihe basis of examination andlor.investigation, in my opinion deatn occurred
<br /> at
<br />causers) stated. n ~ (J U 0 . tne lime, date and place and due to the causetel stated,
<br />
<br />ISign.,",O .nd TmOI .. / {/ fI1-t" 1'il..flc2t;(", b ",1. ISi nalure and Tltlel ..
<br />" 29."DID TOSACCO USE CONTRiBuTE TO THE DEATH?- ".. . ."... AS ORGAN OR TISSUE DONATION SEeN CONSIDERED?
<br />
<br />D YES ~ NO D UNKNOWN D YES ~ NO
<br />
<br />t.J\CH
<br />
<br />M
<br />
<br />27b. DATE SIGNED (Mo.. Dav. Y,.!
<br />
<br />27c. TIME OF DEATH
<br />
<br />28d. PRONOUNCED DEAD IHou"
<br />
<br />30.b WAS CONSENT GRANTED?
<br />
<br />DYES
<br />
<br />l(j NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER [PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNeYI ITVfJ6 arPrml1
<br />
<br />Richard Fruehling
<br />32.. RmlSTRAR
<br />
<br />
<br />idley Ave.,Grand Island, NE 68803
<br />32b. DATE FILED SY REGISTMAyo, ! 3 2003
<br />
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