|
STATE OF NEBRASKA
<br />Y WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH, 4r0laM~t4(~. SERVICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASJ~t' A~~I~~N~'bf,HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR..L~"1`l`Q~h~yC~ORDS`.'~ ~~
<br />~i ~e , j
<br />DATE OF ISSUANCE • ~. W :. • ~ r~~Li,rlk ~ .-' ~ ~~
<br />~A 1 ~Gr d L Q ~Q ~'4~Ly~~ 5. ~OO~R ' •• ri r' ~ ~~
<br />P*I N ~~~
<br />20100377 ~~ ~ ~a,,
<br />LINCOLN, NEBRASKA HFJN~bA~,5EJZlf,1'CE5' ~ ,: Vii. ~d
<br />~} (A~ /~~y ,P,{F,,
<br />STATE pFNEBRASKA-DEPARTMENT GF HEALTH AND Hi1MAN SEFIVICES FINANCE ANA Sly T U
<br />CERTIFICATE OF~EATH °"i' ~`"~~
<br />t. DECEDENT'S-NAME (Flril, Mlddls, Leel, $ultiq 2. SEX 7. DATE OF DEATH (MO.,Oay,Yc)
<br />Marie Jeans Freese Female March 28, 20Q7
<br />4. CITY ANp STATE DR 7ERRlTOp{Y, OR FOREIGN 000NTRY DF BIRTN Se. AGE-Clot 6lrlndq dD. UNDER I YEAR nc. UNDER I DAY 6. DATE OF iIATH (Mo„ Dey, Yr.) ,
<br />(Ytt.) MO$. DAYS HOURS MINE.
<br />Hastin s, Nebraska 83 October 24 1921
<br />7. SOCIAL SECURITY NUMDER ffia PLACE OF DEATH
<br />_.. _
<br />507-140398 : f tl4;slJ7al.~ ~ Ixpepenl QAiES ^ Isailn$Fremi4iC OHotppFtdnly
<br />BD. FACILITY NAME pl not Instituron. plus itrert end number) (] ER/Du~ahenl D peeedentiHams
<br />Saint Francis Medical Center O tXllk O Otrrr(Spsdry)
<br />ffia CITY DR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island eBt3p3 Ha11
<br />W.RESIpeNCE•STATE ib.000Ntt 9cC1TYDR7OWN
<br />Nebraska Hall Grand Island .
<br />90. STREETAND NUMBER Pa, APT. HO 91, ZIP CODE 9$.IN91OE CITY LIMITS
<br />1U7 W. 23rd St. B$$Q1 G~ YES ^ ND
<br />IOs. MARITAL STATUS AT TIME OF DEATH ~I MinNd ^ Never Marnsd 10D. NAME OF SPOUSE (Flat. MIddN. Leri, SuRlx) Il wln, qlw mdden nems.
<br />^Marnsd,buleepenlee C7Wldornd ^Groresd,[]Unknown
<br />HarDld Freese
<br />,~ 11, FATHER-S•NAME (Flnt Mlddls, LeH, Surllx) 12. MOTHER'S•NAME (nnt, Mldtln, Malden Surname)
<br />Jacob 5ittner f=tlzabeth LDfin
<br />13. EVER IN U.S. AAMEO FORCEBY Dlri dgtee hI esNlp If ysi. 1ee.INFORMANT•rU1ME 1/h. RELATIONSNIP TD DECEDENT
<br />(Yn, na orrmk.l No Harold Freese Husband
<br />45. METHODOFDI5POSITION 16s,E LMER-SIG ten. LICENSENO. 19d. DATE (MD., Dey, Yr, )
<br />~ Blrrlal ^ Don^eon /L• ~ 10 7 7 March 30 20tl7
<br />OCnme9al C1EntombmeM tad.CEMETERY,CREMATORYOROTHEALUC I N CITYITOWN STATE
<br />CI Rerrowl Ca Ddler (Speary)
<br />Westlavm Memorial Park Gametery Grand Island Nebraska
<br />17a FUNERAL NOME NAME AND MAILING ADDRESS Stnel, Clly arTown, Snle> ~ 17b, Zlp Code
<br />All Faiths Funeral Hame, 2929 S. Locust 5llreet, Grand Island, Nebraska 68801
<br />ee n+tiructlona an cramp e^
<br />13 PART ). Enllfnn cheM of avlnle••dl!lBeet, Iniudle, or CORIpIICandM-Ihel dlsclly Mu»dlM dfetl1, 00 NOT emir lelntlrul eYrrlli acct et CerdPCenfit APPROXIMATE INTERVAL
<br />nsplntory emit or rerlnldlller nnnnamon wnnoul showlnp Ins sndogy. DD NpT ABBREVIATE, Enlsr pnry ons earns on s Ilna Add eddl9onsl Insi It necerpry. I .
<br />IMMEDUITECIW E: ~ oneNtodealh
<br />bl t
<br />reklPaurrcAUSt~nel
<br />dYMMaeardNalnlllilAr) RUE TO, ORASACONSEOU[NCEOF: I oniMtodealh
<br />hdeerr) 1
<br />aquenBenynelcendnlan,r m1
<br />wy,laedlrptsruenweeled DUETO.OflABACONSEQUENCEOF: I dnasilOdeaet
<br />anrlsa (
<br />EmerelsUNDEALierDCAUSE I
<br />(drsene a Inhey that welagd (c)
<br />IM ewrrYnwANrhdeeeq DUE TO, ORASACONSEpUENCEOF; I enieltodee3l
<br />tleT 1
<br />~ I
<br />fa.PAR711.OTHERS(GNIFICANTCONOITIONS•Candlnoneconld6uhnytahMdHnlnutnotleruldnplnnwundsArlnpcaweQvenmPART1. 19. WAS MEDIGALExAMINER
<br />pRCORONERCONTACTED~
<br />D YEa ND
<br />20. IFFEMALEt Y1e~.M,.yAN~NEROFDeATN 216.IFTRANSPORTATIONINJUr1Y 21aWASANAUTOPSYPERFORMED7
<br />~!lotpregneniwldenpealyaer ~ .YrralYnl t~Htlrrnnde ^DdYHlDDeM101 ^ YES HD
<br />^ Prspninletnmsotdeath ~[,~ACAdM11t~PSndlnphryettlQargn t~Peeeinpel
<br />tJ ^ Psdsslden
<br />~. ^ NolpnpnerM,nulpnpruMwlthlne2deyeofdsefl pgWdps CJ Could notbtdstemVlad 21d,WEREAUTOPSYFlNDINGSAVAILABLE70
<br />~Ndlprpr.re,butprepmnl/7daYilotyeerbelasdielh QOnnr(Swaly) COMPLETECAUSEOFDEATH7
<br />pUnknownupregnanlwlrrinlhspaltyaar ^ YES (]ND
<br />-. ~,~a,p~(:~(~ry.1W}- 6FJ1H61R1~ 2te-irk.AOEOFHiJURwArname,leml~Nreattacloly,slACS~llhknrr~iha
<br />m
<br />22d.INJURYATWORK7 22e, DESCRIBE HOW INJURY OCCURRED
<br />p Yes O ND
<br />22r. LOCATION OF IiUURY • ffiTAEET i NUMBER, APT. aq. CRY/IOIYti SWTE ~ AP CODE
<br />23e,DATEOFDEATH(Mo..DeKYr.) ~e• Y4e.pATEffiIGNED(Mo.,Day,Yr,) 2eb.TIMEDFDEATH
<br />~~ March 26, 2007 ,~s7~ m
<br />27b.DATEffiKiNED Mo.,Day,Yr.) 27c,TIMEOFDEATN ~~ 2fc,pRONOUNCEpDEAD(Mo..Day,Yc) 210.TIMEPRDNOUNCEDDEAD
<br />~~~ 'z.. O a ~ m ~Ilwe~~ m
<br />~ 270. To pl{ hart of my Nnowadga, dHgl dCglmd el ms ime, pin entl pltw s ; ~ 2Ae.On Nle Wept M sxtrrrntion rWlor mrntl~tlon, In rrry dpkllon death oCCVasd tl
<br />E end dus u Ins e>tuee(e) sun . pnehm end nee) • c ~ g ins hme, can and puce end dus n 9w cwup) uaNd. (Srpnetuls end nds - ~
<br />M /~J7
<br />l r' F C1 O
<br />25.DIDTDBACCOUSECONTRIBUTE'T07NEOE,(A/7H? 26e.HASOROANORT188UEDDNATIOHBEENCONSIDERED9 26h.WA8CONSENTGRANTE07
<br />YES NO (~ PROBABLY ~L.1 UNKNOWN ^ YES HO NokApp11ca1NeltR9i li NO ^ YE8 ^ NO
<br />27.NAME.TITI,.EANDAppRESSOF CERTIFIER (PHYSICIAN,CORONER'SpHYSICIANORCOUNTYATTORNEY) (TypsorPnM)
<br />Gordon Hrnicek, M.Q., 729 N. Custer Ave Grand Island Nebraska 68803
<br />I
<br />I 28t REGISTRAR'S SIgNAn1RE 2eo. DATE FILE D BY REDISTRAR (MO„ Day. Yr)
<br />~+i d . ~:~~ APR 6 2007
<br />
|