|
w >v n n
<br />CD
<br />T =D �v
<br />C: �_
<br />zz a M o
<br />_
<br />�--/ m D -' o'
<br />o cn
<br />(� M
<br />o w :
<br />v
<br />CD '-i-
<br />~' Cn G° z
<br />_Z_ '?
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />e tS A THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATWICgS@LIK31y, _WH /CH IS
<br />p C THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />01� DATE OF ISSUANCE -
<br />9/23/2003 2�(j5Q�3� AIs.ER
<br />7.90 ]lSBISTi 1`STA RE64TRAR
<br />or LINCOLN, NEBRASKA HEALTH flI Ate fC�SPY4TEM
<br />K T STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANV3IQdi_FSUPPORT
<br />W yQ F VITAL STAnsncS _
<br />mow 7C' CFRTTFTrAT OF nFATU -- m i 1 l n 1 F) i 3
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX= '' -'_ -
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Anita Sue Dreher
<br />Female
<br />Peptember 16, 2003
<br />4. CITY AND STATE OF BIRTH 11fnot in USA.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Month. Day. Year)
<br />Sb.MOS.I DAYS
<br />5c. HOURS' MINS.
<br />Purdy, Missouri
<br />(Yrs.) 67
<br />June 13, 1936
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />524-40-9609
<br />HOSPITAL ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name (if not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Speatyl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Gran? Island
<br />Yea No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />5c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER !Including Zip Code) 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />3130 W 14th St., #4
<br />K]
<br />28a. DATE SIGNED (Mo.. Day Yr)
<br />28b. TIME OF DEATH
<br />Yes No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (I7 wife, give maiden name)
<br />etc.) (Specify) White
<br />(Sp American ecify)
<br />NEVER DIVORCED MARRIED
<br />LJ
<br />Robert E. Dreher
<br />14a. USUAL OCCUPATION (Give kindol work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />_
<br />15. EDUCATION )Specify only highest grade completed)
<br />of working life, even it retired)
<br />Teacher
<br />Schools
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -1
<br />4
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alfr PC]
<br />Viola (NMI) Sass
<br />18. WAS DECEASED EVER IN U.S. AR ED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no or unk.) PI yes, give war and dates of services)
<br />No
<br />Robert E. Dreher
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />3130 W 14th Street, Apt. #4, Grand Island, Nebraska 68803
<br />20. EMBALM - SIGNATURE &LICENSE 0.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />t_,O
<br />Burial ❑ Removal
<br />September,
<br />20, 2003
<br />Westlawn Memorial
<br />22a. 'F E A HO E - NAME
<br />21 d. CEMETERY OR CREMATORY LOCA I R giFy STATE
<br />Kle' e Funeral Home
<br />❑Crerralion El Donation
<br />Grand Island, Nebraska
<br />221, . FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />3213 W North Front Street, Grand Island, Nebraska, 68803
<br />eo. I-LUTA It l.Awt IEN I tH UNLI UNt UAUSt YtH LINE FUH (a). 10), ANU (0)) Interval between onset and death
<br />PART I
<br />(at , 3 1A Q C4 j
<br />DUE TO, OR AS A CONSEOUENCE I Interval between onset and death
<br />(b)
<br />JUL I U, UH AS A UUNStUUtrvla Ur: I Interval between onset and death
<br />I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />n�
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'S
<br />co r-
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes F No
<br />26a,
<br />26b, DATE OF
<br />INJURY (Mo.. Day. Yc)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />7 Accident F] Undetermined
<br />M
<br />F1 Suicide r7 Pending
<br />26e. INJURY AT WORK
<br />261, PLACE OF INJURY -At home, farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />yes ❑
<br />No
<br />❑
<br />office budding, etc. (Specify)
<br />27a, DATE OF DEATH (Mo.. Day. Yr)
<br />28a. DATE SIGNED (Mo.. Day Yr)
<br />28b. TIME OF DEATH
<br />Cl - 1
<br />'7
<br />L UCJ3
<br />M
<br />i
<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 />M
<br />w
<br />M
<br />?
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />28e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />° °
<br />~
<br />cause(s) stated.
<br />°u
<br />the time, date and place and due to the cause(s) stated.
<br />ISi nature and Title) ►
<br />(signature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO ❑
<br />YYYY'""'"
<br />UNKNOWN
<br />T
<br />1-1 YES IN NO
<br />❑ YES � NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />^fZG�Ic` G. L��ir+6
<br />[i "l.r Zl(�c cc tCZ CI1-t� ME
<br />32a. REGISTRAR
<br />321. DATE FILED BY REGISTRAR (Mo, Day. Yr)
<br />S E P 2 2 2003
<br />
|