Laserfiche WebLink
STATE OF 1�8RASKA- DEPAR7I�Nf OF HF.ALIH A�ID HUMAN SF]tVIC:ES FINANCE APID SWPOItT 3 024 4 S <br />VIfAL STA7'iS'1'ICS <br />' CERTIFICATE OF DEATH <br />1. pECEDENT • NAME fIRST �. MIOq.E LAST � 2 5E% 3. DA1E OF.DEATM /MOMi Da� YNrI <br />Heide Marie Roth Fernale December 26 2001 <br />�. CITY AND STATE OF &RTM /M nuf n U S.A.. ewrN Cpmsyl � � St A6E - lip BiNM�y uNDEP t YEAR UNDER t DAV 6. OATE OF &RTH /Abr/r Dap YNq <br />Hutchinson Minnesota "�" 42 �' � � �"'� �` "°"`� "�' Februar 23 1959 <br />7$OC�AL SECUHTI� NUMBER � � p� PUGE OF DEATM <br />JOS' 7O� � V H4 . . . NOShRAI. ��+�P�M OTMER. � Nur3mg Mome . <br />Bo. FadUTV-Name lNn��nsdubcn.p.sanesrananwndril . � EROu�peUSra � Resaence . . <br />NHS/Clarkson D � ❑ � ��^� <br />8t. CI7Y �tOWN Oii LOCATIpN OF DEATM � Btl. INSIDE CITV lIM1T5 Be COUNTV OF DEATM � <br />Ornaha Y.. Oc � ❑ Douglas <br />9a RESIOENCE - STATE . 9D. COUNTY � . 9t. CITY. Tf,1YVN OR LOCA1iON 9C. STNEET ANO NUMBEF lMduOxg Zp Co7el � 9e INS�pE C(fv INNfTS <br />Nebraska Hall Wood River 11287 W. Capitol Ave. ' �•�� �❑ <br />t0 RACE - le.g, WMk. &uk. MbrKm k�aan. t 1. ANCESTRr ie 9.. ttainn. MeM�can. Gnman. exl t2. � MARAIEp ❑ WIppWEO t3 NAMf OF SPOUSE iD+we avemixibn iwnN �. <br />a�.l1.�e�y) e . ISOSeMI VCrRI`CiTl � � NEVEA dvORCED Ma.nrin Roth � . <br />wnit <br />14a. USUALOCCUPATION lGrveAi7dd /4b KMDOFBUSWESSINOUSTRY 75. EDUCATION fSpscdyonyhgMSt�xlecWnpIBY0) <br />�Nurse d �� Health Care 1� `�++ <br />�una waw �0-,2� n.«s-� <br />16. FATMER - NAME FRST MIDOIE � UST 17 MpTNEA � FIRST MIDDLE MAIOEN SURNAAIE <br />William Dibbern Joy Rathman <br />t8. WAS DECEASEO EVER MI U.S. ARMEO FORCES? .� t9a MIFORMANT-NAME � � � � � <br />lYes. np. a uMC! 1M y�s grve wu antl Cales d anwasl � � � <br />No Marvin Roth <br />19�. INFORMANT MAILING ADOHE55 lS7REET OFi R.F.D. NO.. CITY OR TpWN. STATE. ZIP) � <br />11287 W. Ca itol Ave. Wood River NE 68883 <br />20. EM ER- $IGNA?URE b 110ENSE N0. . 21a. METlq00f q$POSRION 21D. DATE 21[. CEMETERV OR�CREMATORV �- NAME ����-- . <br />�S`D �� ❑�a� Dec, 31 2001 Mennonite Church Cemete <br />MERILL MIOAAE • NAME � � 21tl. CEMETEAV OR CREMAIORV LOCATION � GTY Op TOWk STATE <br />A f el Funera Hane �`""`°^ �°""°°" Wood River NE <br />22b FUNERAL FqME ADOpESS ISTREET OR RF.D. NO.. CRV qi tOWN. STATE, ZIP� . <br />411 W. llth Street Wood River, Nebraska 68883 <br />.� 23 IMMEDIA7E GWSE . IEN7ER ONLY ONE CAUSE PER� UpE FOR ia1. ID1. � Icll ' �"�� ��"M^ �+ ���' <br />PART � 1 � � . . . � . T � , � <br />�� � lal S� JL1�.R � , Lqy$ � . <br />� WE TO.OR I�5 A CplSEWENCE OF � .' . � �� Mrwva� bawe�n msn aro cearc <br />i__ ro� _ Ch roni c Mye loQenous Leukemia ; 2 Years <br />_ - _-_____ _ -__-- -_____ _ <br />� DUE TO.OR AS A CANSEOUENCE OF�. . .. -.. .. � pMrvai beiwsxi awt arw aem <br />lel <br />P � OTMER $IGN61CM17 CONp17pN5� • ConOirpis �' � tplie O�aln pui np1 rN�ISO PART pl IF FEIMLE. WAS TNEFE A 2� AUTOPSV 25. WAS CASE REfERREQ TO MEOICK , <br />� � PFEGNANCV IN TNE PAST 3 MOHTNS� IXAIANEA OR CORp�ER� <br />N� <br />. . � . I�Wes 10.5A1 Ys No X Yas No � Y�s No �( <br />28a. �0. �DATE OF MLNJRY . pla. D�y. Yr.l 26c. MOUR OF MIJURY 2EC. OESLfi�E HOW MUUHY OCCURHEQ �. � <br />D��� ' M <br />� Sueqe � WMrq .: ; 28� MIJURY AT WORIC :". PLACE QF Ip MRV ��. prm. �onel t�pry 28q. LOCATpN STHEET OR R.F.D. NO. CiTV OR TOWN STATE <br />dFa w+a■q. <br />� �� .' �� ,1., Y � � � � , y } <br />�:....-..-..-- . . _., -::t: +,...- <br />m o�� oR o� ' ��.., „� fi ', zs. wre sicr�o nuio. n,r r. � zeo rnae oF o�rn <br />}�,.,�,,�,, � •'.� <br />+�3< LlC4Clt[ � L 1� � � � � g- � . S `�� . � � �. M <br />!!� 27D DATE °�(Ab. �ay'MM � • a .. TW i � . �� 2Bc PRONOUNCED DEA� IAb.. Uh'. Ycl 2M. PRONOUNCED DEAD /Mant <br />� � •• <br />t : <br />J � �C� � � � � M � y � � M <br />� 3�,�� 27d. ,TO �eM . m0 0ue a the �� a 2le. On ne bnis d atiammaso� ana-a n . <br />. nveaegtean. �N u0�+� Oeaer accuna0 • <br />. r� ��': � �$ F! 6rt1l. Cib iM OyC! inE EuQ tl tlM UU8N615�d. <br />�` � . :�� a � � ,�^ � . <br />y . _.._, I���T '. . , ' •� � J - .,.I�wunuMTab � <br />.. _ 29. DID TOBIMC �; SE tON1MiBU ' �MS ORC>AN OR TISSUE DONA4qN BEEN CONSIDERED� 30.0 WI1S CONSENT GRANTED� <br />• t � <br />:. � YES � ���� NO :�:� � ��:.�� . � v :�. . . � vE5 � NO . � � vE5 � NO . <br />� 3t. NAME AMd QF �� :. OR COUNTY AITORNEYI ITN1� ar Ati�ry � . . <br />Robe�� :•• i.ek : B."� ` � Medical Cen�er Omaha NE 68 9- <br />� 32a FiEGIS7iiAH ��� � � r� � •. ar � �' . �' . ��' � � .. �. 32b DATE FILED BV NEGISTRAR /Mi.. Dlry Yrf <br />R � a, ti � ' WY� 2 4 L(},;L <br />, , 11lYi <br />'+�,*.ti� i '�;:_ � <br />, �. <br />This cestiEies>this d�o be a tsns eopy o! an original record oe tile vith Vital <br />Statistics, Douqla� County Health Departaent, Ca�atu, Nebrasfca, Csrtified copies wust have <br />a raised seal in the area to th� le[t; Re�rod�actio�s o! this green certiE#cate ars not <br />leqal copies. � <br />JAN 2 2 � � . �o • <br />Date is�ued: Registr�r: <br />