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<br />I'l
<br />----index against Lot One (1), in Block Seventy Eight (78), in Wheeler and Bennett's Third 5:50
<br />Addition to the City of Grand Island, Nebraska
<br />
<br />N
<br />s
<br />S
<br /><0
<br />S
<br />N
<br />co
<br />......
<br /><0
<br />
<br />'---
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND ffUMAN SERVICES
<br />SYS7EAf, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIQINAL~P.t?RlJ ONFII.E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VltA/!I!!rh ...,;. ...~ N,'/(HICH/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. :fiil-'--; .. ,== .k'"
<br />
<br />
<br />";~;~~;;'" 200902819 (;:~~c~
<br />
<br />LINCOLN, NEBRASKA HEAL1#! __ .... .. ... ., ....,_$'f."EAf
<br />'i:: .~~ :':':',~~'~~', '.: ':~:.':.:,~'t;'" ,:-/ :,::{:,;":'.:,r::"j,g,,~~-,~: i.~~-:' .,',
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTII AND ~iR~~~~~SoI>~"T
<br />. VITALSTATISTICS,..,'",=""......!!.......'..E..'-2'E"(. 0 4 0 2 2 3 0
<br />CERTIFICATE OF DEAljibi~t.''!_\;.~~:'=''''" :.... .
<br />1. DECEDENT - NAME FIRST MIDDLE LAST 2. SE
<br />
<br />4. CITY AND STATE OF BIRTH iI/nO/in US.A. n.",. country)
<br />
<br />Edgar, Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />Gilbert
<br />
<br />
<br />Leslie
<br />
<br />Nelson
<br />
<br />22, 2004
<br />
<br />5a. AGE. Last Birthday
<br />IYro.1
<br />
<br />UNDER 1 YEAR
<br />5b. MOS. DAYS
<br />
<br />24, 1916
<br />
<br />UNDER 1 DAY
<br />5c. HOURS' MINS.
<br />
<br />6. DATE OF BIRrH (Month.OllY. YfJarj
<br />
<br />87
<br />
<br />8b. FACILITY - Nam.
<br />
<br />507-38-5584
<br />
<br />f" not institution, g;WJ street an(J rI/,Jml>>f)
<br />
<br />80. PLACE OF DEATH
<br />HOS~lT AL; 0 Inpallenl OTHER: [!] Nursing HOrne
<br /> 0 ER Qutpatl&nt 0 ReSidence
<br /> D DOA D Other (Sf)eclfvl
<br />8<1. INSIDE CITY LIMITS
<br />
<br />Beverly Health Care-Lakeview
<br />~e. CITY, TOWN OR LOCATION OF DEATH
<br />
<br />'Grand IsYand
<br />
<br />9a, RESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />
<br />
<br />MAIDEN SURNAME
<br />
<br />9<1, STREET AND NUMBER {lncllJdlng Zip COde/
<br />
<br />9.. INSIDE CITY LIMITS
<br />
<br />Hall
<br />
<br />Grand
<br />
<br />68801 Yo. IX] No 0
<br />13. NAME OF SPOUSE (#wile.g;veme~nnemel
<br />Helen Spitz
<br />
<br />10, RACE. ,o.g" WhilO. Black. Amoncan Indian.
<br />Ole.IISp.clly, Wh it e
<br />
<br />11. ANCESTRY la.g.. 11a."". Ma.I.an, G"""an. ""'I
<br />ISpec,fy'American
<br />
<br />Nursing Home
<br />
<br />16. EDUCATION (Specify only hlgheOl grado compl..ad)
<br />EI8msntary or Secondary 10-121 College (1-4 Or 5"'1
<br />12
<br />
<br />18. FATHER. NAME
<br />
<br />140. USUAL OCCUPATION IGiv.~!ndol_*<IOn<Idtirlngf1lO$/
<br />of working /Ifil, 8V8n If r8t1rBdJ H 0 use K e e per
<br />
<br />MIDDLE
<br />
<br />FIRST
<br />
<br />
<br />Helen Nelson
<br />
<br />17. MOTHER
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />Arthur
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Yes. no. or unk.) IIf yes. give war and dates of service.}
<br />No
<br />
<br />19b. INFORMANT
<br />
<br />Frances
<br />
<br />Cavett
<br />
<br />MAiliNG ADDRESS
<br />
<br />ISTREET OR R.FD. NO" CITY OR TOWN. STATE. ZIP)
<br />
<br />
<br /><;
<br />
<br />Island, Nebraska
<br />210. METHOD OF DISPOSITION
<br />
<br />21 e. CEMETERY OR CREMATORY. NAME
<br />
<br />68801
<br />21b, DATE
<br />
<br />t 10 7 1 [1g Burl.1 D Removal 25 2004 west:lam RnDrial Park
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Funeral Home OC.....- DOonilliOn
<br />,STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />
<br />Grand Island,
<br />
<br />Nebraska
<br />
<br />All Faiths
<br />22b. FUNERAL HOME ADDRESS
<br />
<br />2929 S. Locust St.
<br />
<br />
<br />Grand Island, Nebraska
<br />/ENTER ONLY ONE CAUSE PER LINE FOR /a\. Ib). AND lell
<br />
<br />68801
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />kat4-
<br />
<br />Interval between onset and deall1
<br />
<br />! V-LdL<-
<br />
<br />Interval between onset and deatl1
<br />
<br />02~
<br />
<br />{ldeir.P 4uda/Z
<br />
<br />ICI
<br />PART OTHER SIGNIFICANT CONDITIONS. C"'d.ion. conlnbu~ng to lno do.." bu' nOl ",I.lad
<br />
<br />II
<br />
<br />-+~ ~~~d8am-
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />""'0.
<br />0 Accident 0 Undetermined
<br />0 Suicide 0 Pending
<br />0 Homillide Investigation
<br />
<br />250. INUURY AT WORK
<br />y..D NoD
<br />
<br />
<br />
<br />31.
<br />
<br />261>. DATE OF INJURY (Mo.. Day. Yr.} 2ee. HOUR OF INUURY
<br />
<br />26g. LOCATION
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />STREET OR R.F.D. NO.
<br />
<br />270. DATE OF DEATH (Me" O.y. Yr-l
<br />
<br />25a DATE SIGNED (Mo.. Oay. Yr-l
<br />
<br />25b. TIME OF DEATH
<br />
<br />2004
<br />
<br />.-;ai
<br />IH~
<br />
<br />J!I~z
<br />~~8
<br /><> "
<br />
<br />M
<br />
<br />21lO. PRONOUNCED DEAD (Me.. Oay. Yr.!
<br />
<br />2ed. PRONOUNCED DEAD (Houri
<br />
<br />A.M
<br />
<br />M
<br />
<br />288. On !tie basis of examination andrO( Investigation, In my opinion death occurred at
<br />the time. date and place and due to the cause(sJ stated.
<br />
<br />30.b WAS CONSENT GRANTED?
<br />D YES "~NO
<br />
<br />{Tn>> or PrintJ
<br />
<br />John A. Wagoner, M.D.,
<br />32.. REGISTRAR
<br />
<br />Grand Island Nebraska 68803
<br />32b. DATE FILED BY RlOlARRR (Me" fY' 2'604
<br />
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