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<br /> WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br /> SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDJON_FILE WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7I$1IC qTMb1if .*0ftCH IS
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br /> DATE OF ISSUANCE
<br />
<br /> 10/17/2003 200902741
<br />
<br /> ASSISTANT" TEy)-;w
<br /> G 1 F~.
<br /> LINCOLN, NEBRASKA HEALTH AND HLIKAN SERiiii6 8~` E11~=
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER~f~SjNA71EE AND SUPPORT
<br /> VITAL STATISTICS CERTIFICATE OF DEATH 03 11540
<br /> . DECEDENT - NAME FIRST MIDDLE LAST 2, SEX 3.u DATE ]FE,
<br /> TH /McNh. Day. Year)
<br /> Robert Walter Chr stal Male Octer 9, 2003
<br /> 4. CITY AND STATE OF BIRTH IN nxN kr USA.. name couaey) 5a. AGE - Last BlrMday UNDER 1 YEAR UNDER 1 DAY 6. DAIRTH lMOnM. D
<br /> y Yar)
<br /> (YrS.), MOSDAYS Sc. HOURS' MINS.
<br /> Rice Lake, Wisconsin 81 aar 21, 1922
<br /> 7. SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH
<br /> HOSPITAL• Inpalianl OTHER Nursing Home
<br /> • 390-18-2071 - ® ❑
<br /> 8b. ACIUTY • Name (gro! Makurdon, give -and ❑ ER Outpatenl ❑ Residence
<br /> St.Francis Medical Center ❑ DOA ❑ Other lSFaci/vt
<br /> iC. CITY. TOWN OR LOCATION OF DEATH 8d. WSIDE CITY LIMITS Be. COUNTY OF DEATH
<br /> I
<br /> Grand Island, Nebraska
<br /> Yea ® Ne ❑ Hall
<br /> go. RESIDENCE • STATE 8b. COUNTY 9c. CITY, TOWN OR LOCATION Bd. STREET AND NUMBER /including Zip Ccde) ge. INSIDE CITY LIMITS
<br /> Nebraska 68803
<br /> Hall rand Island 1911 N. Howard Yea® Nn❑
<br /> 10. RACE - (e.g., White. Black. American Indian.. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc( 12, © MARRIED ❑ WIDOWED 13. NAME OF SPOUSE g! wile. give maiden name)
<br /> etc-1 ISpec8yl Whit e Ispec.h9 American NEVER DIVORCED R o s a 1 i e= , F ugh
<br /> r14a. L OCCUPATION !Give kkMdl work done during moat 14b. KIND OF BUSINESS INOUST13 15. EDUCATION ft -e
<br /> onl hi heal rode cam leted
<br /> rirg Ula, oven kre6redl (Pe 9 g p I
<br /> Elamemary a ndary 1012) ollage 114 or 5•I
<br /> Manager Holida~ Conoco Static
<br /> R - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br /> niel `NMI ' Chr stal Viva NMI Welson
<br /> ECEASED EVER IN U.S. ARMED FORCES? 9aIr+ or or&) (11 yes. give war and dates Sarvkaa y~y~ &
<br /> ,y T`w Yes Korean 1~39~196 22 s Rosalie Chr stal
<br /> ! l 9b. INFORMANT MAILING ADDRESS ISTREET OR RF,D, NO., CITY OR TOWN. STATE. ZIP(
<br /> 1911 N. Howard Grand Island, Nebraska 68803
<br /> C* lh 20. EMBALMER - SIGNATURE 8 LICENS O. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br /> ~w r Bullet Removal OCt•11,2003 estlawn Memorial Park
<br /> Pil, HOME - NAME
<br /> 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br /> Kleine Funeral Home ❑Dremwgon ❑Dea,wn Grand Island, Nebraska
<br /> 2Ln1r. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br /> ry 3213 W. North Front St. Grand Island, Nebraska 68803
<br /> P. 6-+ 3. IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE F -;2-- Nc I Interval between tinsel and death
<br /> PART 1
<br /> DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br /> I
<br /> +A'
<br /> rot I
<br /> C~- I
<br /> r>Y!~,' DUE TO.OR AS A CONSEQUENCE OF. Inierval between onset and death'
<br /> '1 I
<br /> I
<br /> ICI 1
<br /> OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE, WAS THERE A AUTOPSY WAS CASE REFERRED TO MEDICAL
<br /> PART PREGNANCY IN THE PAST 3 MONTHS?
<br /> EXAMINER OR CORONER?
<br /> (Ages 10-541 Yes NO Yes No i Yes 11 Np'
<br /> 1 4 28a. 28b. DATE OF INJURY lMa. Day. Yr.) 26c. HOUR OF INJURY 2nd. DESCRIDE HOW INJURY OCCURRED
<br /> c ~
<br /> Yi! Accident Undetermined
<br /> yn{ M
<br /> 13 'Suicide Pending 2Se. INJURY AT WORK 281, oLAe E AA nNJURY /At ho8ra, farm, sheet, factory
<br /> 28g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br /> prj Homicide Investigation Y. ❑ No ❑ MII 6u71 ei 9Pecn1')
<br /> I a, DATE OF DEATH /A/p., ay, Yr. 28a. DATE SIGNED (Mo.. Day, Yr.) 28b. TIME OF DEATH
<br /> g © 0
<br /> . DAT
<br /> .
<br /> W/b E SIGNED / Day. Yr.J 7z. TIME ^ OF DEATH 28c. PRONOUNCED DEAD /Mo.. Day, Ycl 28d. PRONOUNCED DEAD (Hour)
<br /> To the best of m knoWad9death accu at 81e 8ma, date and lace and due to the M
<br /> P 288 on the basis of examination and-or investigation, in my opinion death occurred at
<br /> yid-'! causefs) stated,
<br /> b 01 the lime, dale and place and due to the cause(b) slated.
<br /> y? f'"~ IS nature and Tine (Signature and Thiel ll~
<br /> DID 709A000 USE CONTRIBUTE TO THE t=,"' a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? WAS CONSENT GRANTED'
<br /> p:W.~ ❑
<br /> ❑ YES NO ❑YES No YES -M Iy-~ No
<br /> _NAME A E AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER "5 PHYSICIAN OR COUNTY ATTORNEY) /Type W prMfl "--"cc--"
<br /> Gordon J. Hrnicek, MD, 729 N Custer Ave., Grand Island, NE 6$803
<br /> .ti [1 32e. RE I6 RAR 32b. DATE FILED BY ReiS
<br /> T 15 TRA lino.D0o
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