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. WHEN TH/S COPY CARRIES THE RA/SED SEAL Of THE NEBRASKA STATE DEPARTMENT Of l�EALTH, /T CERT/F/ES THE BEL OW TO BE A TRUE COPY OF AN OR/G/NAL RECORD UNF/LE`W?H THE STATE DEPARTMENT OF HEALTH, BUREAU Of V/TAL STAT/ST/CS, WH/CH /S THEIEGAL lJEPO�lTOR1� FOl� V/TAL RECORDS. DATE Oi /SSUANCE - � � "� ' '- DEC 2 41996 2 0110 � 4�� qSS/STAN 37ATEREG/ST/�Ali _. __ 1/NCOLN, NEBRASKA NEBRASKA bEPAliTMENT OF HEALTH STATE OF NEBRASKA - DEPARTMENT OF HEAtTk - BUREAU OF VITAL STATISTICS CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SE7( 3. DATE OF DEATH /MOntn. Day YeaQ Kathleen E. Mason FemaZe December 11, 1996 d. CITY AND STATE OF BIRTH /prrot in U.SA.. name counlryJ Sa. AGE - Lasl BiMday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIFTH /MOnCY. Oay Year/ Rockville, Nebraska IVrsI �� SGMOS. DAYS ScHOURS' MINS N�Vem 27 1924 � 7. SOCIAL SECURTlY NUMBER 8a. PLACE OF DEATH 507-88-9346 HOSPITAL: � Inpa�ierrt OTHER � NursingHOme Bb. FACILITY-Name /HrwfinsMUtion,givestreetaiMnumberi � ER'Outpatient � Resitlence Community Care of America ❑ ooA ❑ a�e�rsce�� 8c. CITY. TOWN OR LOCATION OF DEATH � � I Bd. INSIOE GTY LIMITS 8e. COUNTV OF OEATH i Central City i,.8g n No I� Merrick 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITV, TOWN OR LOCATION 9d. STREET AND NUMBER /Inc/uding Zip Code) 9e. INSIDE qTV UMITS Nebraska Hall Grand Island 1117 W. lst ST. 68801 �eg� No ❑ 10. RACE -(e.g.. White. Black. American Indian. 11. ANCESTRV le.g.. Italian, Me:ican, German, etq 12. � MARRIED ❑ w100WED 13. NAME OF SPOUSE lI/ wile. give maiden name/ etc.�ISpecify) (SOeMYI NEVER DIVORCED Lonnie Mason White American i4a. USUAL OCCUPATION /Give kiMO/workdone dunngmasf `` taD. KIND OF SUStNESS tNDUS7RY \ 15. EDUCATION �Speary only �iqbesl grade completed) olworkirrqlde,eveni/retired) \1'� �O ElementaryorSecontlary 10-t2� �� College I�-aor5�1 Homemaker � Domestic �� 12 ---- 16. FATHER-NAME FIRST MIDDLE LAST t7. MOTHER FIRST MIDDLE MAIDENSURNAME Dan NMN Cronin F.ti enia NMN Patton 18. WAS DECEASED EVER iN U.S. ARMED FORCES? 19a. INfORMANT - NAME � (Yes. no. or unk.� (If yes. give war arW dates oi services) NO ------ Lonnie Mason 19b. � INFORMANT MAIUNG ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1 W. lst St., Grand Island, Nebraska 68801 20. MER - SIGNA U 8 L E N . w � / 21a. METHOD OP DISPOSITION 21b. DA7E 21c. CEMETERV OR CREMA70Rr . NAME 7 V .� Qe��a� ❑Remo�a� Dec. 13 1996 Grand Island City Cemeter; 22a FUNERA E- NAME 27d. CEMETERY OR CREMA70RV LOCATION CITY OF7 70WN STATE L'ivin�ston-Sondermann F.H. �Crematbn ❑Donatio� Grand Island, Nebraska 22b. FUNERAL HOME ADORESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP� 505 West Koenig, Grand Islanfl, Nebraska 68$O1 . 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR Isl. (b�. AND (cp Interval between onset anU Oeath ,/ PAFT ) � /"� �a) ��Z�7 �/IM� � �,k i �� l ��`� DUE TO, OR AS A CONSEQUENCE OF. i Interval between onset arid tleatn �b� I DUE 70, OR AS A CONSEOUENCE OF T^ �� i Interval between onset antl tleatn i i �c� i OTHER SIGNIFICANT CONDITIONS - Cmtlitions coMri�uling to the deat� bul no� related PART III IF FEMALE. WAS Tr1EFE A �q AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? X �(, EXAMINER OR CORONER? 11 �AgeS 10-54) Yes No Yes No (� ves No 26a. 26b. DATE OF INJURV /MO.. Dey, Yr.J 28c. HOUR OF INJUFV 26d. DESCRIBE HOW INJURV OCCU RED � Accident � UntletermineU M � SuiciAe � Pendin9 26e. INJURY qT WORK 26f. PLAC�O�F,�JURY %A� farm, street laclory 26g. IOCATION S7REET OF F.F.D. NO. CITY OR TOWN STATE ❑ ❑ oll'ce w i etc. S n}/ � Homicitle invesfigation Yes No � 27a. DATE OF OEATH /MO.. Day. Yc/ � � �- 28a. DA7E SIGNED /MO.. Day. n.) 28b. TIME OF DEATH !�-�� �s � � I�� .� w M � 27b. DA7E SIGNED lMO.. Day. Yc) 27a TIME OF DEATH � � g 28c. PRONOUNCED DEAD (MO. Day, Yc) 28G. PRONOUNCED DEAD /HOUr1 z M ��_� M �g� � r�1,�(9� u a��o5 sz� g °� 2T�y To ihe Gest of my knowleGqe. death occurred at ume, t nd place and due to Me °�� 2Ba. On Me basis o� e.amination anaior investigation, in my opinion death xcurred et �� causels� sWted. ~° a �he �ime, Eare and Dlace antl tlue to the cause�s� stated. � � �Signature and Title � �""``�' Si nature and Title 29. DID TOBACCO USE CONTRIBUTE T HE DEATH? 30.a HAS ORGAN OA TISSUE DONATION BEEN CONSIDEREDI 30.0 WAS CONSENT Gf7ANTED? � � VES �NO � UNKNOWN � , /� YES � NO � YES � NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICWN OR COUNTY ATTORNEY) lType or Pnnt/ Dr. Steven Mahnke � LONe TRE� Ma`�rc.�� /IS,s .,eres aS(v Is It�E. �e„q ��'f� �cbr GPP i 32a. REGISTRAR 32b. DA7E FILED BV REGISTRAR /MO., Day. Yr./ �._ �EC 2 3 1996