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i WHEN THIS COPYG4RRIES THE RAfSED SEAt OF THE NEBRASKA HEAlTH AND �� RVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/GINAL RE�R_B£JIV ElL�-�F1TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V/TAL SFAT/ST� �C�RJJIi`T�f;1S THE LE(iAL DEPOSITORY FOR V1TAL RECORDS � � DATE OF /SSUANCE � �� _ ' , r ��Y� t`-�#O�-� MAY 2 8 2002 - - - - - - LINCOLN, NEBRASKA 2 0 i 10 4 7 3 �, LTH I�D FlI�i4 S 11FS,�1ll�l�� 11� �-z ,;.��- A.. _r _ STATE OF NEBRASKA- DEPAR'IMENT OF HEALTH AND HUMAN SER�Ft�(AI�iC�AN��[7pppRT V1TAL STATISITCS � _- -- - 0 2 0 5 9 3 3 CERTIFICATE OF DEATH ; 1. DECEDENT - NAME FIRST MIDDLE � LAST � �� 2. 5EX � � 3. DqTE OF 6EATH ,MOmn. DaK year� Pernadine Rose Williams Female May 7, 2002 4. CI7V AND STATE OF BIRTH /Brtotbr US.A. neme counlM' Sa AGE - Last Birfhday UNDER 1 VEAR UNDER t DAY 6. DATE OF B�RTH /Month, Dae Year/ Norfolk, Nebraska r�� l � Mos. � DAYS Sc.HOURS M�NS. February 16, 1931 7. SOCIAL SECURTIY NUMBEA Ba, PLACE OF DEATH � 507-32-3153 Ha�R� � inpatient. OTHER � Nurs�ngHOme �Sti: FACIUTY • Name (lf trot institufion, grve sfreef artU numbe� � ER dulPeuen� ! � pesidence Park Place Nursing Home ❑�^ �°�1��'�� 8c. CITY. TOWN OR LOCATION OF D�HTH 8d. INSIDE CIN LIMRS 8e. COUNTV OF DEATH Grand Island Y� � No ❑ Hall 9a. RESI�ENCE - 3TATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION ' 9d. STREET AND NUMBER (fncfuArhgZ'rpCadBl 9e. INSIDE CITV UMITS � Nebraska Hall. Grand Island 220 East 12th, 68801 Y� � No ❑ 10. RACE - �e.g, Whita. 81ack. American Indian. 71. ANCESTRY Ie.g.. italian. Mexican, �erman, etcl 72. � MARPoED ❑ WIpOWED 13. NAME OF SPOUSE � wile. givemardan namel et°.iis°�'`'�lhite � American "�' °"oR°EO Gene Wi113.ams ❑ MA RI D ida. USUAL OCCUPATION (Give k6td ol wortc done dWing mast 14b. KtNO OF BUSiNESS �NOUSTRY 15. EDUCATIOt3 �Speciy only highest grade compiete0) � ol working 1'de. even Nretlied� - Elamentary or SecorMary 10-t 2j ' Coliege It -4 or 5�1 Nurses Aid Nursing Care Home 12 16. fATHER - NAME FlRST MIDDLE � LAST 17.. MOTHER � FIRST MIDDLE MAIDEN SURNAME Glenn Deuel Neva M. Rice 18. WAS DECEASED EVER IN U.S. ARMED FOACESY 19a INFORMANT-NAME (Yes. no. or unk) pl yes. give war and dates of servicesl No Gene Williams 19b. � iNFORMMIT MAILING ADDRESS ISTREET OR R.F.D. NO.. CffY OR TOWN. S7ATE. Z1P) � �,� 220 East 12th, Grand Island, NE. 68801 20. EM LMER - SIGNATURE 8 LICENSE NO. LJ� r` 21 a METHOD OF DISPOSITION 216. DATE 21 c. CEMETEfiY OR GREMATORY - NAME ) J ��, �]� Ma I0, 20p2 Mt. Hope Cemetery 22a. FUNERAL 1�1 ME - NAME . � 21 d. CEMETERY OH CREMATORY IOCATION CITV OR 70WN STATE Apfel-Butler-Geddes ❑�^ ❑°onaM Scotia, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR RF.D. NO.. CITY OR TOWN. STATE, ZIP� � 1123.West Second, Grand Island, NE. 68801 23. IMMEDIATE C0.USE IENTER ONLV ONE CAUSE FEF LIPfE fOR IaL Jb}, APdD �c�) ' 1 Interval beM1veen onut and deatn Pnar (` . I i '/`' O ' �e� \.t�r't�to`('��l �^� � i� rt'� , � OUE T0. OR AS A CONSC-0U CE OF: I Irrterval beM�een onset and tleatYi i �� ° N 1-�. ' ' �.o�+� � �� , _ _ � � DUE T0. OR AS A CONSEOUENCE OF: � i Ifrterval bertvCen onset antl Aeam i i �� I PART OTt{Efi� IGN�IFI - Cantli6ons conhibu(im� W the death bW not relatetl PART 111 IF fEMALE. WAS THERE A 2d. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL N/ / PRE6NANCY IN 7HE PAST 3 MONTHS? EXAMINER OR CARONER? �� p t y� - � �(� _1 Q ..� �� (Ages J 0-54) Yes No Yes No Yes No � �x � �c�� 26a. � 266. DATE OF IN,IURY (Mo.. Oay. Yr.J 26c. HOUR OF INJURY 28d. DESCRtBE HOW tNJURY OCCURRED � � AcciAeM � Undetermirted ry� � Suicitla � Pending 26e. INJURY A7 WORK 26f. PLqCEQF.INJURY - At hom9, farm. streel. taclory 26g. LOCA'f70N STREET OF1 R.F.D. NO. CITY OR TOWN STATE ❑ � ❑ ❑ ottice bu�ldi�. etc. ISpeciryl Homicitle �nvestigaGOn Yes No � 27a DATE OF DFATH /Mo.. Day. Yr.l � - 28a DATE SIGNED /MO.. Day Yr.l 28b. 71ME OF DFATH . . j�� Scgi¢ M �.� 2Tb. DATE S10NED /Ma.. Day Yc) 27a TIME OF DEATH �� T �� PRONOUNCED DEAO (MO.. Day, Yr.J 28d. PRONOUNCED DEAD /HOUd �° _ �-1 -c�- 3`� �O R � .- � o � ° M M �z� $ 27d. 7o the best of rtry knowletlge. tl occurred at the tlrtre, tlate antl P ce and due 10 the .° o° �. �^ �� °� e�'amit�aa^ antl�°( inYesagati°°• in my opininn death occurrad at cause(sl slated a � me tlme. daze and p�ace arw aue ro Me cause(s) slated r 1Signatuce and Title ► Si napue and TNe .� 29. DID TOBACCO USE CONTRIB THE EA 7 a ORGAN OR TISSUE DONATION BEEN CANS ED? 30.b WAS CANSENT GRANTED? � VES NO � UNKNOWN � YES C 10 � � YES NO 37. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATfORNEY� (7yP9 aPrintl Kimberly A. Mickels M.D. J2 N. Cus e Ave., Grand Island NE 68803 32a REGISTRAR . � 32b. DATE FlLED BV REOISTRAF �(MO.. Day, Yt/ � .�it, MAY 2 3 2002