|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU "Aj RVICES
<br />SYSTEM R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGIMAL RECIOM Offs -C1Y TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEt FC,. 4N NCHW_S =
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE l
<br />Aft
<br />1/7/2005 asslsr�nrsr wZ as
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES ORT "+ -
<br />CERTIFICATE OF DEATH - - 14407
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH !Mont. Day Yearl
<br />Iva Lou Stoulp
<br />Female
<br />December 27, 2004
<br />4. CITY AND STATE OF BIRTH /Knot kr U.S.A.. name country]
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day. Year)
<br />(�
<br />(Yr$.) 71 sb.
<br />MOS. I DAYS
<br />5c. HOURS MINS.
<br />April 23, 1933
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -34 -9239
<br />a
<br />ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (ff not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specly,
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />ra
<br />=
<br />D
<br />Yes ❑x ❑
<br />Hall
<br />ca
<br />p-
<br />CD
<br />r
<br />I
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /krcludingZip Code)
<br />Z
<br />Nebraska
<br />S\
<br />Grand Island
<br />1016 East Phoenix Ave. 68801
<br />Yea © No El
<br />;Z: �
<br />N
<br />12. ® MARRIED 1:1 WIDOWED
<br />13. NAME OF SPOUSE In wrta give maiden name/
<br />eta! (Specify) White
<br />(Specify) Danish
<br />NEVER DIVORCED
<br />MA
<br />Raymond Stoulp
<br />14a. USUAL OCCUPATION /Give kind of work done dun'ng most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Housewife
<br />--1 M
<br />CD
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Soren C. Jensen
<br />Ida C. Andreasen
<br />18. WAS DECEASED
<br />`
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.)
<br />NO
<br />(6 yes, give war and dales of services),
<br />Raymond Stoulp
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1016 East Phoenix Ave. Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 6 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE - 21c.
<br />CEMETERY OR CREMATORY NAME -
<br />Not Embalmed
<br />❑ wel ❑ Removal
<br />�
<br />r
<br />c.rn
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home
<br />©crema6m ❑ Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 W. 2nd St. Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)) I Interval between onset and death
<br />PART I
<br />'
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />_
<br />�
<br />o
<br />=
<br />`
<br />111 IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />124
<br />IN THE PAST 3 MONTHS?
<br />m
<br />A ..
<br />(Ages
<br />Tj
<br />:�
<br />O
<br />Yes No
<br />f
<br />C�t5
<br />26b. DATE OF INJURY (Ma. Day. Yrj
<br />26c. HOUR OF INJURY
<br />2" DESCRIBE HOW INJURY OCCURRED
<br />F Accident F-] Undetermined
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />, farm, street. factory
<br />PLAe E I F INJURY %ASPS
<br />MN AC n}'1
<br />26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No 1:1
<br />126f.
<br />a3')
<br />-
<br />o
<br />27a. DATE OF DEATH (MO.. Day. Yr.)
<br />28a. DATE SIGNED IMO.. Day. Yr.)
<br />�
<br /><
<br />December 27, 2004
<br />< W
<br />Dec 29, 2004
<br />12 : 4 0 pm M
<br />�
<br />27b. DATE SIGNED (MO.. Day. Yr)
<br />n
<br />�'
<br />28d. PRONOUNCED DEAD (Hour,,
<br />�•
<br />T
<br />g
<br />1310 M
<br />W'i
<br />Dec 27, 2004
<br />12:40 pm M
<br />CT)
<br />cn
<br />N
<br />e-t
<br />cause(s) stated.
<br />Z5 a
<br />the time, date and place art due)d cau ae(s staled.
<br />�// Hall Co A t t
<br />(Signature and Title) �
<br />(Signature and Title ►
<br />29. DID TOBACCO USE CONT-R�IBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRAFTED?
<br />rJ
<br />❑ YES I NO ❑ UNKNOWN
<br />❑ YES 13 NO
<br />NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Mark J Young, Hall County At orney, 231 S Locust, Grand Island, NE
<br />32a. REGISTRAR
<br />32b. DATE FILED BY ZMIT R (MDaWL U5
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU "Aj RVICES
<br />SYSTEM R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGIMAL RECIOM Offs -C1Y TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEt FC,. 4N NCHW_S =
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE l
<br />Aft
<br />1/7/2005 asslsr�nrsr wZ as
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES ORT "+ -
<br />CERTIFICATE OF DEATH - - 14407
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH !Mont. Day Yearl
<br />Iva Lou Stoulp
<br />Female
<br />December 27, 2004
<br />4. CITY AND STATE OF BIRTH /Knot kr U.S.A.. name country]
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day. Year)
<br />Mirage Flats, Nebraska
<br />(Yr$.) 71 sb.
<br />MOS. I DAYS
<br />5c. HOURS MINS.
<br />April 23, 1933
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -34 -9239
<br />Inpatient OTHER:
<br />- HOSPITAL ❑ E] Nursing Home -
<br />ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (ff not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specly,
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑x ❑
<br />Hall
<br />No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /krcludingZip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1016 East Phoenix Ave. 68801
<br />Yea © No El
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g. Italian, Mexican. German, etcl
<br />12. ® MARRIED 1:1 WIDOWED
<br />13. NAME OF SPOUSE In wrta give maiden name/
<br />eta! (Specify) White
<br />(Specify) Danish
<br />NEVER DIVORCED
<br />MA
<br />Raymond Stoulp
<br />14a. USUAL OCCUPATION /Give kind of work done dun'ng most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Housewife
<br />Domestic
<br />Elementary or Secondary 10.121 College 11 -4 or 5 -1
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Soren C. Jensen
<br />Ida C. Andreasen
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.)
<br />NO
<br />(6 yes, give war and dales of services),
<br />Raymond Stoulp
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1016 East Phoenix Ave. Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 6 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE - 21c.
<br />CEMETERY OR CREMATORY NAME -
<br />Not Embalmed
<br />❑ wel ❑ Removal
<br />Dec 28, 2004
<br />Westlawn. Memorial Park
<br />22a. FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funeral Home
<br />©crema6m ❑ Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 W. 2nd St. Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)) I Interval between onset and death
<br />PART I
<br />I
<br />(al I
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />(b) Respiratory arrest 30 min
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(c) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />111 IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />124
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER R CORONER?
<br />(Ages
<br />10.54) Yes No
<br />Yes No
<br />Yes No
<br />268.
<br />26b. DATE OF INJURY (Ma. Day. Yrj
<br />26c. HOUR OF INJURY
<br />2" DESCRIBE HOW INJURY OCCURRED
<br />F Accident F-] Undetermined
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />, farm, street. factory
<br />PLAe E I F INJURY %ASPS
<br />MN AC n}'1
<br />26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No 1:1
<br />126f.
<br />a3')
<br />-
<br />27a. DATE OF DEATH (MO.. Day. Yr.)
<br />28a. DATE SIGNED IMO.. Day. Yr.)
<br />28b. TIME OF DEATH
<br /><
<br />December 27, 2004
<br />< W
<br />Dec 29, 2004
<br />12 : 4 0 pm M
<br />27b. DATE SIGNED (MO.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /MO.. Day. Yr.)
<br />28d. PRONOUNCED DEAD (Hour,,
<br />T
<br />g
<br />1310 M
<br />W'i
<br />Dec 27, 2004
<br />12:40 pm M
<br />§
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />289. On the basis of examination and, or investigation, in my opinion death occurred at
<br />cause(s) stated.
<br />Z5 a
<br />the time, date and place art due)d cau ae(s staled.
<br />�// Hall Co A t t
<br />(Signature and Title) �
<br />(Signature and Title ►
<br />29. DID TOBACCO USE CONT-R�IBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRAFTED?
<br />rJ
<br />❑ YES I NO ❑ UNKNOWN
<br />❑ YES 13 NO
<br />NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Mark J Young, Hall County At orney, 231 S Locust, Grand Island, NE
<br />32a. REGISTRAR
<br />32b. DATE FILED BY ZMIT R (MDaWL U5
<br />y
<br />
|