|
<br /> ~ ~~ r--->
<br /> .:"'" 0 (fJ
<br /> <=
<br /> Ii' ~ c.= 0.-4
<br /> n3: ""- c:::t>
<br /> n Z ?Ii: .--\( (".- :z.....-;
<br /> ,.. ~!~ ::0 .....-;(Tl
<br /> :J:~C z -<0
<br />'" t ~cnW <;) "
<br />Gl 0"" ........... o"'T1
<br />S ~:z: N "'T1 Z
<br />CO i! C) " t~
<br /> :J: rn
<br />S CJ po. CD
<br />S rn t \:J r ::;0
<br />..... rn ::3 :I>
<br />OJ D r
<br />S (j1 (fl
<br /> !I c..:> /">
<br /> :I>
<br /> -C ......... .""-"
<br /> -:J (fl
<br /> (f)
<br />
<br />
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE _MAMA HEALTH. AND HiiilAI(SERVlCES
<br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OIIIWIAL REC.QBP_C>N FlU. WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL s~~It1t"'s
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . Iffij~~~-";: '~=~~1'~-~ .11~'~f~'.,l'i"
<br />
<br />. ,. .'.'~~,'
<br />DA TE OF ISSUANCE 0 1 8 0 ~"'" - - . r<= -'- -- TI "
<br />1 0/21/2003 200 9 O",~: 1. :si~~_:~~:&rl1:;# ',.;
<br />LINCOLN, NEBRASKA HSA~TH~"iti'~~~l@S.~M
<br />. , -, ':',;~,':"";',:.:i\",: "!..~-:,'-:~-;;.<,:'~-..;._)"'''- :~;':", ,:'.. ,~~'~'""=' ~--=-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALtH AND ~~~~!:'::,fa:(~VS):!~R1
<br />CERTI;:~S~~~ri~iTa~f~'~;:.~1~=-: ,5' - 03 11 719
<br />
<br />'. OECEDENT - NAME FIRST MIDDLE LAST ;'11. SEX
<br />
<br />Ruth
<br />4. CITY AND STATE OF BIRTH 1/1 nOlln U.S.A.. nom. counlTy)
<br />
<br />une Powell
<br />50. AGE. Last Blnndoy UNDER 1 YEAR
<br />(Y".I 5b. MOS. DAYS
<br />82
<br />
<br />
<br />1921
<br />
<br />Hall Count , Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />aO. PLACE OF DEATH
<br />HOS~ITAL;
<br />
<br />Nursing Home
<br />
<br />o
<br />o
<br />o
<br />
<br />~
<br />o
<br />o
<br />
<br />Inpatient
<br />
<br />OTHER:
<br />
<br />508-16-9266
<br />ab: FACILITY. Nomo
<br />
<br />(If not institution, give strHl and numbflr)
<br />
<br />ER Oulpotlont
<br />
<br />ReSidence
<br />
<br />DOA
<br />
<br />OIhor (SpgCli:-,
<br />
<br />Lakeview Nursin
<br />ac. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />L.9rand Island
<br />".~ lIIibTDEN"l::"'"5fl1lll: ........ .
<br />
<br />Rehab Center
<br />
<br />
<br />ad. INSIDE CITY LIMITS
<br />
<br />
<br />NUM~tH (InClU<1ln9':IP~_' .~i:lI;;iW"--
<br />Yo. ~ No 0
<br />'3. NAME OF SPOUSE III Wile. glVfI "",idBn nomoi
<br />
<br />Nebraska
<br />10, RACE:. (e,g.! Wl'llte. Black. American Indian,
<br />oto.jISpocity)
<br />
<br />Hall Aida
<br />11. ANCeSTRY le.g.. Italian. Mexican. Getman. etel
<br />ISpecify)
<br />
<br />William Powell
<br />, 5. EDUCATION (Specify only highest grodo completed)
<br />Elementoryor Sooondary 10-12) CollogoI1.4or5.,
<br />12
<br />MIDDLE MAIDEN SURNAME
<br />
<br />American
<br />14b. KIND OF BUSINESS INDUSTRY
<br />
<br />White
<br />140. USUAL OCCUPATION IGivo kind o/work cIono during most
<br />of working II/e, 0_ /I roffrodl
<br />
<br />lB. FATHER. NAME
<br />
<br />Clerk
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />First
<br />LAST
<br />
<br />I John Philli
<br />~ 1 a. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />l (Yes, 110, or unk.l IIf yes. give wEir and dEdas 01 serviceS)
<br />
<br />Nodine
<br />
<br />Ouimett
<br />
<br />no
<br />19b. INFORMANT
<br />
<br />William Powell
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP}
<br />
<br />MAILIN(l ADDRESS.
<br />
<br />#10 Venus Street AIda
<br />
<br />W;~.r~r~~r)S~
<br />
<br />22.. FUNERAL HOME - NAM~
<br />
<br />Nebraska 68810
<br />210. METHOD OF DISPOSITION
<br />
<br />21b. DATE
<br />
<br />21c. CEMETERY OR CREMATORY NAME
<br />
<br />t:{JJ
<br />
<br />16, 2003
<br />
<br />Oct.
<br />
<br />~ Burial 0 Removal
<br />
<br />Grand Island Cit
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />
<br />D Cremation 0 Donation
<br />
<br />A fel-Butler-Geddes
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY O~ TOWN. STATE. ZIP)
<br />
<br />
<br />112 West Second
<br />23. IMMEDIATE CAUSE
<br />P~R:, M u... \+-c S
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF"
<br />
<br />..5.. e" ev\. (\ \..' uJ"
<br />
<br />1
<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 REFERRED TO MEDICAL
<br />EXAMINER OR CORONER? .
<br />
<br />Interval between onS91 aM death
<br />
<br />W\ir\^.~5.
<br />
<br />Interval between onset and deatl1
<br />
<br />'( e f\..ft1
<br />
<br />,
<br />ot...
<br />\
<br />
<br />o....;\.rwL', 0 s.c-~C \--'~
<br />
<br />od~t.~ C\..j ~
<br />
<br />Ib)
<br />OUE TO, OR A~ A.CQNSEQUENCE OF:
<br />
<br />Interval between onset and deatn
<br />
<br />
<br />D Accident 0 Undete~mjned ~
<br />D Sulold. D Pending
<br />D Homic.:idB Investigation
<br />
<br />ST~EET OR ~.F.D. NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />289, LOCATION
<br />
<br />~l!
<br />U,.
<br />!..g
<br />.~
<br />B~
<br />~~
<br />
<br />27a. DATE OF DEATH 11.10.. Oay. Yr.)
<br />
<br />\~ - \"""".)- C:l~
<br />
<br />27b. DATE SIGNED 11.10.. Oay. Yr.)'
<br />
<br />\t) - \~-
<br />
<br />2ao. DATE SIGNED lMo.. Oay Yr.)
<br />
<br />2Bb. TIME OF DEATH
<br />
<br />
<br />M
<br />
<br />260. PRONOUNCED DEAD lMo.. Oay, y,)
<br />
<br />2ad. PRONOUNCED DEAD IHou"
<br />
<br />M
<br />
<br />288. On the basis of examination a.nd/or investigation. jn my opinion death occurred a.t
<br />the time, date and place and due to tha cause(s) !itated.
<br />
<br />3O.b WAS CONSENT GRANTED?
<br />o YES
<br />
<br />~NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYj (Typg or PrinQ
<br />
<br />Dr. Steven
<br />320. REGISTRAR
<br />
<br />
<br />t
<br />Grand Island, Nebraska 68803
<br />32b. DATE FILED BY REGISTRAR lMa.. Oay. Yr.)
<br />OCT 2 0 2003
<br />
<br />
<br />Lot Ten (10), ArgoFourth Subdivision, in the Village of AIda, Hall County, Nebraska
<br />
<br />0 m
<br />N
<br />a ~
<br /><=)
<br />C.D 6;
<br /><=) z
<br />0 ~
<br />:n
<br />l--" c:
<br />co i:
<br />~
<br />0
<br /> Z
<br /> 0
<br /> ~
<br /> \.J'\,
<br /> ~~
<br />
|