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<br />_~Recorder's Memo for Register of Deed Recording Space
<br />WFIEN TMS COiPYCrll~tf 1ff RAISED SEAL OF THE A!B1bit
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<br />1611 l~ALTH/
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<br />SYSTENa R CER7ff/ES TIC BELOW t0 BE A TRUE COPY OF THE OR/C,:1NA'~,: ~:CiI~
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />'
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<br />SYSTEM, VITAL
<br />STATj~/
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<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~-
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<br />
<br />DATE OF ISSUANCE -
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<br />2oo9os512 - -- ~~
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<br />A~~N1'STAT~S7~G~
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<br />LINCOLN, NEBRASKA HEALTHA~11-~~~M
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<br />STATE OF NEBRASKA.- DEPA1tTME:NT OF HEALTH AND I I[1MAN ~ ~r ,
<br />~~L~iSUPPORT
<br />VITAL STATISTICS ~i ~~-~ ~ ~,
<br />CERTIFICATE of nF.;4TH ~ `'i ~ ^ ~ .~
<br />`"S `~
<br />1. DECEDENT • NAME FiFST MIDDLE LAST ^. SEX s_. ;, 3 GATE pF DEATH /Month. pay. VearJ
<br />Donald Dale Forst Male -March 19, 2003
<br />4. CITY qN6 STATE OF BIRTH /grmf kr U.S.A., name rdunfry/ 5a. AGE • Lass Binhday UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /Month pay, Year/
<br />Grand
<br />Is
<br />land
<br />~ Nebraska
<br />IVrs.l 50. MOS. DAYS 5C. HOURS
<br />MINS.
<br />~0
<br />..
<br />,
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<br />- Au ust 7, 1922
<br />7. SOCIAL $ECURTIY NUMBER .
<br />8a PLACE OFDEAYH
<br />508-18^5362 HOSPITAL ^ Inpatient OTHER: ^ Nursing Horne
<br />86. FAGLITY -Name /!lndl maa7ulion. give 5erea! and number) ^ ER Outpatient ® Residence
<br />3222 W. Fai.dle Ave. ^ DDA ^ orher (Speedy,
<br />&. CITY, TOWN OR LOCATION DF DEATH tld. 1NSIDECITV OMITS Bq. GOUNTy OF DEATH
<br />.
<br />Grand ?Stand Yes ~ N~ []
<br />hall .
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<br />. 9c. C11V, Tt71M/f)R'L06AT .'9Tk1E "AND NU 'lpkkl~Zkr 00003 9E. INSIDE CITY LIMBS
<br />Nebraska Hall Grand Island 3222 W. Faidle Ave. Yea ® Nd ^
<br />10. RACE • (e.g., White. BIBCk. American Indian, 11. ANCESTRY le,g., ltallan, Mezicen. Gemran, etcl t2, ®MARRIED . ^ WIDOWED 13. NAME OF SPOUSE /d wde. give maiden name/
<br />5
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<br />etc,11
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<br />Nl Y.rG ite ISpeclNl A.,,~riL`an NEVER DIVORCED
<br />Wll t]W Marceline Yvonne Schoel
<br />Ida. USUAL OCCUPATION /Glue kind o/ la~7rk done dunng moss
<br />al14Vlkklg lNe. even drefr7edl 14b. KIND pF BUSINESS INDUSTRY 15. EDUCATION (Specity only Highest grade completed)
<br />
<br />Service Repairman Ele to or dndary 10-121 ~ College It-4 ar 5•I
<br />Heating & Air Service ~th ~rade
<br />18. FATHER-NAME FW57 MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Joseph Forst Mary Ault
<br />18. WA5 DECEASED EVER IN U.S. ARMED FORCE57 19a. INFORMANT -NAME
<br />(Yes, nd. Ix unk.l III yes. give war Ertl dates of aervloeel
<br />No _-_____~ Marceline Forst
<br />196. INFORMANT MAILING ADDRESS (STREET OR R.F.b. ND.. CITY OR TOWN. STATE, XIP1.
<br />3222 W e Av Grand Island Nebraska 68803
<br />' 20. EM - $KiNATURE 8 O. ~~ 27a. METHOD OF DISPOSITION 210. DATE 21 c. CEMETERY OR CREMATORY -NAME
<br />f" ~ ®Sunal ^Remowal Mar. 24, 2003 Westlawn Memoxial Park
<br />22a. FUNERAL - NAME ~ 21d. CEMETERY pR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston-Sondermann F.H. ^Cremalion ^Denatgn Grand Island, Nebraska
<br />220. FUNEFlAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN . STATE. ZIP(
<br />601 N. Webb Road, Grand Island, Nebraska 68803-4050
<br />~ 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Isl. lbl. AND Icll I Interval between Onset and deatn
<br />- PART ~
<br />-~ Ilal Natural causes ;y unknown
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between Onset end death
<br />1
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<br />Ibl ~
<br />~,...~N1E 70,1Mi AS A CONSEOVENC'c OF: ~ Interval between onset and death
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<br />OTHER SIGNIFICANT CONDITIONS - Cdnditans wnbibutlrg b ale dea810rA rwt related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? ~ ~ EXAMINER OR CORpNER?
<br />IA9es 10-541 Vas No Ves No Ves No
<br />26a. 25b. DATE OF INJURY /Mp., Day Yr) 25c. HOUR OF INJURY 25d. DESCRIBE HOW INJURY OCCURRED
<br />i ~ ACCtlem ~ Undetermined
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<br />Suicide ~ Pending 28e. INJURY A7 WORK 261. PLACOR INJURY • t hq7 , term, she9t, IaCWry 28g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />i ~ HaNcide Invesgge8on V~ ^ ,~ ^ odllfiice nq, etc. /~PeC~'I
<br />r • -. "••. ` "• "`^, • • n.+r.....7. „V era. 'AILS ED /Md., pa , Yrl 266. TMAE OF DEATH
<br />~ 28--03 ~ 8:00 m
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<br />270. DATE SIGNED /Afq, pay Yc/ 27C, TIME DF DEATH v ,PRONOUNCED DEAD lMo.. Oay, YcJ 28d. PRONOUNCED DEAD /FburJ
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<br />~~ M ~~ aPlarch 19, 2003 ~` 9:30 pm
<br />27d. To the best d my knowledge. death occurcetl at me lima, date and place and due b dro ~ v 26e. On the Oasis W ezamina ror ~ igation, in my opimm~ death cecurrad al
<br />ceuselsl stated. a
<br />. tl1a dne. date and Wece due ro
<br />= I (5igneWne and Title - $I nature and Title
<br />- 29, DID Tp$ACCO VSE CONTRIBUTE 70 THE pEATH7 30.a HAS GROAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />'~ ^ VES ^ NO ~ UNKNOWN ~ ^ YES ~ NO ~ ^ YES ® NO
<br />31 Ny~/~AE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( /TyP ' J
<br />Sgt J Rodriguez-~ GTPO, 13 S Loc s~ Grand Island, NE 68801
<br />329. REGISTRAR 32b. DATE FILED 8V REGISTRAR /Mo., pay Yc/
<br />1 ~ APR 2 ~nn~
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