Laserfiche WebLink
. � 1 . . � . . . .. <br />WHEN TH/S COPY CA�S THE R/tlSED SEAL OF THE NEBRASKA HEAl:TH AND H!J►yiAN SERVJCES <br />SYSTEII� IT CFRT/F/ES THE BELOW TO BE A TRtlE COPY OF THE ORtO/NAf.-R� �ON FYtE ��H <br />THE NE6RASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT�T1� ., � <br />THE LEC3AL DEPOS/TORY FOR V1TAL RECORDS. _.,. ���. <br />DATE OF ISStlIhNCE � � � � � � - � <br />� �� � .�, <br />c ��iV�cEY S� , <br />JU� �3 2001 2011028�5 ,��,�`--� <br />LINCOLN, NEBRASKA HEALTM��Jl/A�4N�R'�7 �`Si�M <br />STATE OFNEBRASKA• DEPARTMEN'L OF HEAL'CEI AND F�fAi�7S� <br />1f�NCFk,�ND S R'C <br />,��. STA�s��� _ 1 -� �� 0 7 6 9 0 <br />CERTIFICATE OF DE" ;r__,..r ? <br />� DECEDEN7 - NnME FiFST nmDDi.E LaST � . 2-S . 3 �ATE Of DEATH iMann. Da��. Vear� . <br />Velma Janette Kiser ` Female `� July 13, 2001 <br />4. CITV AND STATE OF BIRTH lI/nof in USA.. name Counlryl 5a AGE - Last Biqhtlay � UNDER i YEAR � � UNDER 1�DAV � 6. DATE OF BIfiTH /MOnNr. Day Year/ <br />�Vrs I Sb MOS '� DAVS 9C. HOURS' MINS. � <br />Shelby, Nebraska 64 ' May 14, 1937 <br />--- --- - <br />7 SOC1Al SECURTIY NUMRER 88 PLACE Of DEATH � � � - ' � � � � - J � <br />� HOSPITAL'. ❑ Inpalient OTHEF �� ❑ Nurs��g HOme <br />505-38-5917 ---- - --- <br />Bb. FAGLfTY - Name !I7 nol mslNfion, give sheet anp number/ � ER Ou�pa�ient � � ResiAenCe <br />1 N. Engleman Rd. ❑ °OA ❑ °'^e-!s��,", <br />Bc. Ci7v. TOWN OR LOCA7iON OF DEATH - 8d 7NS�DE C�TV LIMRS ee COUNTV OF DEATH <br />Gr and Island Yes � No ❑ Hall <br />9a. RESIDENCE - STATE 9b. COUN7Y � 9c GTV. TOWN OR LOCATION � 9a. STREET ANO NUMBER lmdutling ZipCode�G $HO3 9e. IN$IDE C�TY UMITS <br />V <br />N Hall Grand Island 1617 N. En leman Rd. ' �es� No❑ <br />f0 RACE �(e g., White. 81ack. Amenian Indan. 1 t. ANCESTfiv le.g. Ilalian. Mex�can, German, etcl � 12. � MARRIED ❑� WIDOWED 73 NAME OF SPOUSE NI wAe. grve maiden name� . <br />e1c.IlSoec�tyl . lSpecdyl NEVEH DIVORCED <br />White American MARRI Donald Kiser <br />taa USUALOCCUPATION (Groekindolwo�adonedurirrgmos� iab KMDOFBUSINESSMDUSTRV 15. EDUCATION �Specityonlyh�ghestgredemmpleletl� <br />o/wo�king7i/e, eveni/ie�ireuil . � - � E�ememary or Secontlary 10-i2) � College �i �4 or 5-i � <br />Homemaker pomestic lOth Grade <br />16. FATHER � NAME FIRST MIDDLE LAST R. MOTHER FIRST MIDDLE MAIDEN SUFNAME <br />William Funkhouser Rub Ella Solomon <br />�8. WnS DECEASED EVERIN U.S.ARME� FORCES7 79a MFOiiMANT-NAME <br />�Ves, no. oi unk.� � yes. g�ve=ar a�tl tlates M services) . � <br />No Donald Kiser <br />19b. INFOAMANT MAIUNG ADDRESS �STREET OP R.F D NO.. C�TY OR TOWN: S7ATE ZIP� <br />1617 N. En leman Rd., Grand Island, Nebraska 68803 <br />20. EMBALMER - SIGNATURE 8 UCENSE NO. 21a UETNOD OF D15POSITION 27C. DATE � � 21c. CEMETEFV OR CREMATOFV - NAME <br />Not Embalmed �]e�,;a, �qemoval July 13, 2001 Central NE. Cremation Serv <br />22a. FUNERAL HOME - NAME 27d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston-Sondermann F.H. ❑ C�emalion ❑o��a„o� Gibbon, Nebraska <br />22b. FUNERAI HOME ADDRESS �STREET OR R.F.D. NO.. C�TV OR TOWN. STATE. ZIP) . <br />601 N. Webb Road, Grand Island, Nebraska 68803-4050 <br />23. IMMEOIATE GAUSE . (ENTER ON� ONE GAUSE P R LINE FOR Ia1. Ib�. AN �� � i Interval iween onsei and dea <br />PART � �. . .. <br />I <br />� lai � �� - Q <br />DUE TO, OF AS A CONSEOUENC OP , I � In rval between on5et n tleath <br />`/ 't) O I � � . <br />Ibl I <br />DUE TO. OR AS A CONSEOUENCE OF � � - i iMerva� nd tlealh <br />Icl <br />OTHEF SIGNIFICANT CONDITIONS - Ca�ditions coMriDuting ro the death but not rela�etl PART III IF FEMALE. WAS THERE A 2a. AUTOPSY 25. WAS CASE REFERRED 70 MEDICAL <br />PARi . PREGNANCY IN TNE PAST 3 MONTHS? ExAMWER OF CORONER? <br />II <br />IAqe510-5<I Ves No �}Yes No .�� Ves Ko <br />26a. 26b. DATE OF INJURY /MO.. Day Yr/ 26t. MOUfi OF INJURY 2EA. DESCRIBE HOW INJURY OCCURRED <br />� .4cc��den1 � UntletermineA M . <br />�� Su�ode � Pentling 26e. WJURY AT WOPK 26C PLACE OF IN.IURY - At home, fa�m, sveet. tactwy � 26g. LOGATION STREET OR RF.D. N0. CITV OF TOWN STA7E <br />i ❑ oM�ice �uiltling. etc lSpec��y/ <br />Homicide � InvestigaGOn y� � N ❑ � <br />' � I 27a. DATE OF DEATH /MO. Day Vr) � 26a. DATE SIGNED /Mo.. Day Vr.l 28b. 71ME OF �E0.TH <br />� �� � � � > <br />$� 27b. DAT IGNED j / Da . Y� 27c TIME OF DEATH . �`° � 28c. PRONOUNCEDbEAD /MO.. Day, VcJ 28C. pqONOUNCED OEAD /hbuil M <br />� g ° � � / � 'I' �o�. d.5 i` M � ¢ i � • � M <br />Q 27tl. io the besl of my knowled deat occ etl at the ti ate antl place antl tlue io the g�° 28e. On Ihe basis of examinallon arM or investiganon, in my opinion tleatn occunetl at . <br />�auselsl stated. � � � �°� the iime, date arM place and due �o the causels� sWled. <br />(Si nature anA TRIe� � � (Si naNre anU Title) � . <br />29. DID TOBACCO USE CONTRIBU THE DEATH? a HAS ORGAN Ofi TISSUE DONATION BEEN G 30.b W AS CONSENT GRANTED? <br />� � � YES � NO UNKNOWN , �� �p . �;.� � YES ��O <br />��� <br />31. NAME AND ADDRESS� CEFTIFIER IPHYS�CIAN, CORONERS PHYSICIAN OR COUNTY AT70HNEYI rTYpe prPnntl <br />S' � • 1 �- LL� _ .� � -- J 2. l� r a n,� � S�u, r� 3 <br />32a REGISTRqq � 32b. DATE FILEO BV RE ISTRAR /M¢.Oay. Ycl <br />- - _ ���;�,� �,,.�,�� JUL 1 7 2001 <br />