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IIM1M~N TH/3 COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN $EA`VICES
<br />SYSTEM,IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI[iINAL RECORG`ON Fll,~ IMTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIGS SE~C1'IO~S=-=:
<br />THE LEQAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE ~ -?
<br />~1 ~~g1VL~'~ S. COOPER
<br />9/ 1/ 2 0 0 4 2 p p 9 0~ 4 5 '~ ASS/STANr ~TA"rl~ R~l~~'R~l~
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SESYSTEIId
<br />STATE OF NEBRASIKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FiNANC&,ANA ItT _. • -
<br />VTfAL STATISTICS _ - _ -
<br />CERTIFICATE OF DEATH - - ^, (~ ~ (~ Q a ~ q
<br />t. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. GATE QF DEATH /Month. Day. Year)
<br />Gerald Ra Eilenstine Male August 23, 2004
<br />4, CITY AND STATE OF BIRTH !ll not M USA., Hama cbunfry/ Sa. AGE • Last Birthday UNDER 7 YEAR UNDER 1 DAV 6. DATE OF gIRYH /Month. Day. Year)
<br />St. Michael, Nebraska (Vra.l
<br />82 56, MOS. I DAV5 5c. HOURS' MINS.
<br />November 16, 1921
<br />r 7. SOCIAL SECURTIY NUMBER Sa. PLACE OF DEAYN
<br />I
<br />1 505-22-3213
<br />HOSPITAL: ® InpetlerR OTHER ^ Nmsmg Hdme
<br />8b. FACILITY -Name /h Hat instimNoq glue street and number) ^ ER Outpafiem ^ Residence
<br />~ St. Francis Memorial Health Center
<br />i ^ ooA [] Otber /s~e~,,yl
<br />8C. CITY, TOWN OR LOCATION OF DEATH 9d. INSIDE CITY LIMITS 8e. GOUNTV OF pEATH
<br />Grand Island - Yew-® No {] - - ~ Hall..-_.. .
<br />9a. RESIDENCE -STATE 94. COUNTY 9C, CI Y. TOWN OR LOCATION 9d. STREET AND NUMBER llnclrrdhrg Z/p Gddel 9e. INSIDE CITY LIMITS
<br />Nebraska Hall Wood River 1208 Marshall St. 68883 ve3 ® Nd ^
<br />10, RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le.g.. 6allan, Mexican. Gannon, atcl 12. ®MARRIEp ^ WIpOWEO 13. NAME OF SPOUSE (Ir wile. give maiden name)
<br />etc,llSpecityl
<br />White ISPe~Ityl American NEVER DIVORCED
<br />Darlene Obermiller
<br />t4a~ USUAL OCCUPATION /Give kind o/ work done dudrrg most 14b. KING OF BUSINESS INDUSTRY 15. EDUCATION (Specity only highest grade Completed)
<br />1 o/work/°g k/e'e`ren dra6redJ
<br />• Farmer
<br />Agriculture Elamarnary or Secondary 10-12) ~ College It-4 or 5~1
<br /> +1
<br />i 16. FATHER • NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIppLE MAIDEN SURNAME
<br />Raymond Eilenstine Joyce McDonald
<br />18, WAS DECEASED EVER IN U.5. ARMEp FORCES? ~ 190. INFORMANT • NAME
<br />(Yes. no, dr unk.l III yes, give wet and dates of services) 5/23/44
<br />Yes ww n 9/15/45 Darlene Eilenstine
<br />196. INFORMANT MAILING ADDRESS (STREET OR R.F,D. NO.. CITY OR 70WN, STATE. ZIP(
<br />1208 Marshall St. Wood River, Nebraska 68883
<br />2D. EM6ALMER -SIGNATURE 8 LICENSE NO. 21 e. METHOD OF DISPOSITION 21 b. DATE 27 C. CEMETERY OR CREMATORY NAME ~ .
<br />a~~-315-
<br />
<br />^X Budal ^ Removal Aug 27, 2004 Westlawn.Memorial Park
<br />22a. FUNERAL H E .NAME 21tl, CEMETERY OR CREMATORY LOCATION CITY OR TOWN SYAYE
<br />Apfel-Butler-Geddes Funeral Home ^ cremaNan ^ DDnahw Grand Island, 68803 68803
<br />224. FUNERAL HOME ApORE55 (STREET OR R.F.D. NO.. CITY OR TOWN . STATE. ZIP(
<br />1123 W. 2nd 5t. Grand Island, Nebraska 68801
<br />123, IM (ATE CAUSE
<br />PART
<br />I
<br />(al ~~ •1
<br />~ DUE TO.OR AS A CO UENCE O
<br />DUE T0. OR AS A CONSEQUENCE OF:
<br />CAUSE PER LINE FQR lat. (bl. AND (CI(
<br />I (Mental between onset antl death
<br />I
<br />I
<br />1
<br />I Interval betvreen ohs and death
<br />between onset and deals
<br />"'
<br />OTHER SIGNIFICANT CONDITIONS ~ Candilions caMribudng la the de nut not relgted
<br />PART
<br />PART III IF FEMALE. WAS THERE A I
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />~
<br />II ..,,~~~...aa~.. PREGNANCY IN THE PAST 3 MONTHS? EXAMINER pR CORONER?
<br /> IAgas 10-54) Ves Na Yea NO Yes NO
<br />2Sa, 28D. GATE F INJURY /Ma.. Day cJ 28c. HOUR OF INJURY 28d. DESCRIBE HOW INJUPV OCCURRED
<br />Accident ~ Undetermined
<br /> M
<br />Suicide ~ Pending 28e. INJURY A7 WORK V ~A~dyp' farm, street, factory
<br />28L plfloe bullplnp BUtcR
<br />3 28g. LOCA710N STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation yes ^ No ^ .
<br />/
<br /> 27a. DATE OF DEATH /Ma. Day. YrJ 28a. DATE SIGNED /Mo.. Day. Yc1 29b. TIME OF DEATH
<br />~~ August 23, 2004 ~ r
<br />~- ~
<br />M
<br /> 27b. DATE SIGNED /Md,. Day. Yr,/ 27c. TIME OF pEATH ~ G 28c. PRONOUNCED DEAD /Mo.. Day, Ycl 28tl. PRONOUNCED DEAD /Hourl
<br />~g~ August 26,2004 rn M ~i~ M
<br />W ~ 27d. To the best of my pwledge, dea ocdmred a Imo, oaf and place and due to the
<br />) ° ~ ~ 2Be. On the heels oL Bkeminaaon and~ar investigation, In my Opinion death occurred at
<br /> dauaalsl eta}ed. 1 8 the time, dale and place and due b ILIA causals) stated.
<br />__ I " (Signature and TItl9) - ISi nature and Tde
<br />29. DID TO&4000 USE CONTRIBUTE T0. E EATH? 30.d HA$ ORGAN OR TISSUE DONATION BB EN CONSIDERED? 30.6 WA$ CONSENT GRANTED?
<br />
<br />^ VES ~,' NO UNKNOWN
<br />^ VE5 ~
<br />NO ~''J_
<br />^ VE5 I )Q} NO
<br />•C'
<br />3t, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type a Pdnp
<br />Ryan Crouch, D.O. 800 Alpha rand Island, Nebraska. fi8803
<br />32d. REGISTRAR 326. DATE FILED BY REGISTRAR /Md., pey Yr./
<br />~:~ AUG ~ 1 2004
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