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<br />WHEN THISJ;OPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL 711 A~I!,#;IUMJW'sM"'I!~fiS.. <br />S~TE~ IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE...t;l?RQ~-f.lLE''''#; <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VlTALSTATlSUf:ltSEOOONi'fWlICH"IS,., <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . '!Jl;t!;filf'(ii;/A'~':'/a*;j", <br /> <br />D~ ;E/02F 'gs/su2AONCOE4' 200 80998 4 ~'f71~.,J_v~i~~~...:"t;I.!!t:~,;:;, <br />A~SISTANJr~T4 fil$TtMIl ',:t~'i,J~r,. <br />LINCOLN, NEBRASKA HEAL THAN'tHY!;'!f~\c'-i. . .'~W:FfI!i.'~t/:f'n::,: <br />STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND lIllMA:N',gEi~'-'" "~, ." ""&...~R:PI"~t;jk':'" <br />YITALSTATISTICS . '. ~.=7;~;;;",.=~Jt~dl~~-4^'"):'1}2""'7 3 5 <br />CERTIFICATE OF DEA l]f"cc~o:.:-/~~L:-::'i':oi.c=U' .' ","\f' '. <br />1. DECEDENT. NAME FIRST MIDDLE LAST <br /> <br />Hildreth. Nebraska <br />7. sOCiAL SECURTIY NuMBER <br /> <br />B.. PLACE OF DEATH <br /> <br /> <br />2004 <br /> <br />Francis <br /> <br />Henr <br /> <br /> <br />Purd <br />Sa. AGE - Lasl Birthday UNOEFl1 YEAR <br />(Y".I 5b. MOS. DAYS <br />89 <br /> <br />DATE: OJ= elRTH (MonttJ. D~y. Y&8r) <br /> <br />4, CITY AND STATE. OF 61RTH If/ not IfI u.s.A. nami;! ~auf1tryJ <br /> <br />'6b. FACILITY. Name <br /> <br />(If 001 mstltulJotl. gillB street and number) <br /> <br />HOSPtT AL: 0 Inpatient OTHER: <br />o Ef:l Ol,llPijtienl <br />o DOA <br />ad. INSIDE CITY LIMITS CO-UNTY OF DEATH <br /> <br /> January 3. 1915 <br />[J Nur$lng Home <br />0 Residence <br />0 Orner ,Specrlvl <br /> <br />507-05-5134 <br /> <br />Wedgewood Care Center <br />Bc. CITY. TOWN OR LOCATION OF DEATH- <br /> <br />Grand Island <br />9;'. RESIDENCE - STATE <br /> <br />9b. COUNTY <br /> <br /> <br />Ve. [Xl No 0 <br /> <br /> <br />Hall <br />STREET AND NUMBER !Including Zip COde) <br /> <br />ge INSIDE CITY LIMITS <br /> <br />White <br /> <br />Hall Grand Island <br />11 f ANCESH:jY fe 9 Italian Mel(lI::an. German, etcl 112. ~ MARRIED <br /> <br />(Soe"tyl Am . D NEVER <br />er~can MARRIED <br />14b KINO OF aUSINESS INDUSTRY <br /> <br />Ve. [Xl No D <br /> <br />Nebraska <br /> <br />10, RAce -.{e.g., White: Black. Americillllndian. <br />",c.IISP.cllyl <br /> <br />13. NAME OF SPOUSE (II wife. give maider'l r1~m~) <br /> <br />14a. l.ISUAL OCCUPATION (Give kiM of work done during most <br />of working life. even if fBI'redl <br /> <br />'''''Funeral Director <br />---.-- <br />16. FATHER - NAME FIRST <br /> <br />MIDDLE <br /> <br />Mortuar <br />LAST <br /> <br />17 MOTHER <br /> <br />Francis <br /> <br />William <br /> <br />Purdy <br />19.. INFORMANT. NAME <br /> <br />Gretchen <br /> <br />Emilie <br /> <br />Weinstock <br /> <br />16.'WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yes. no. Or unk.} (II yes. ~lv9 war a.nd dales of Mlfvioel!il <br />Yes WIl. 9 / 181!9~1-11/21/l94 <br />190. INFORMANT MAILING ADDRESS (STREET OR RFD. NO. <br /> <br /> <br />)06 S. Harrismn Grand Island <br />20. M8ALMER --SIGNATURE & LICENSE NO. <br /> <br />.~~:tt(143 <br /> <br /> <br />Nebraska 68803 <br />21.. METHOD OF DISPOSITION 21b. DATE <br /> <br />21c. CEMETERY OR CREMATORY NAME <br /> <br />[jisu,;.1 o Removal Nov. 22. 2004 Grand Island City Cemetery <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br /> <br />~ivi~gston-Sondermann F.H. <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.b.' NO.. CITY OR TOWN'. STATE. ziPI <br /> <br />o Cf8ma~on 0 DanallOn <br /> <br />Grand Island. Nebraska <br /> <br />_6Qt N. Webb Road, Grand Island. Nebraska 68803 <C <br />23. IMMEDIATE CAUSE ,-----._..... (ENTER ONLY ONE CAUSE PER LINE FOR lal. (bl. AND (ell <br />PART /"," .._. /) . r . r' /7 <br />.\ir' I (al ~~~ L...--<?-_~,--- <br />DUETO.ORASACONSEOUE~OF'----- .- ----- . <br /> <br />(bl <br />DuE I O."OA AS A CQNSI;QUENGt=. 'O~. <br /> <br /> <br />InlBrlt'al between onset and dealll <br /> <br />26a. <br />0 ACCident 0 Undetermined <br />0 Suicide 0 Pending <br />0 Homicide Invesllgation <br /> <br />26b. DATE OF INJURY (Mo.. Day. Yr.) 26e. HOUR OF INJURY <br /> <br />PART III IF FE;MAlE, WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br /> <br />(Ag., 10-541 !~.5__D _ NO 0_ <br />2M DESCRIBE HOW INJURY OCCuRRED <br /> <br /> <br />.i\...".j <br />I nset and deaIh <br />I <br />I <br />I <br />I Imerval oerween on!;!:!! arid dealn <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br /> <br />Ve. 0_ No &f __ <br /> <br />(el <br />PA~T OTHER SIGNIFICANT CONDITIONS - Condilions l:onlrlbutlng 101M dealh but not relal9cl <br /> <br />II <br /> <br />26e. INJURV AT WORK <br />Yes 0 No 0 <br />27.. DATE OF DEATH IMO.. D.y Yrl <br /> <br />M <br />261. ~ffi~~~u~~~~~~~Y -,t~fY" larm, streel. factory <br /> <br />26g. LOCATION <br /> <br />STREET OR RF.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />2B.. DATE SIGNED (Mo.. Day YO <br /> <br />28b TIME OF DEATH <br /> <br />E" ~ <br />~Q <br />j~>- 27b. <br /> <br /> <br />~~~ <br />];;>-:3 <br />-!i",S~ <br />5~>-~ <br />~~~ <br />~ 8,~ <br /> <br />M <br /> <br />26e. PRONOUNCED DEAD IMo.. Day. Yr) <br /> <br />2Bd. PRONOUNCED DEAD (Houri <br /> <br />M <br /> <br />28e. On Il1e ba.sis of examination and'or inve5~gation, in my opinion death occurred at <br />Ine lime, date and pla!::e aM clue 10 11'18 causers) slated. <br /> <br />30.b WAS CONSENT GRANTED? <br />DYES <br /> <br />NO <br /> <br />...r Dr. <br />32.. REGISTRAR <br /> <br />Gordon J. <br /> <br />729 N. <br /> <br />Custer. <br /> <br />Grand Island. NE 68803 <br />32b. DATE FILED BY REGISTRAR IMo.. Day. Yr.! <br /> <br />NOV 2 2 2004 <br />