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, . � s :
<br />' WHEN THIS COPYCr4RR/ES THE RA/SED SEAL, OF THE NEBRASKA HEALTHANI� HUMAN SE/iWCES ,,: ,
<br />SYSTEM, !T CERTIF/ES THE BELOW Tb BE A TRI/E COPY OF THE O/t(f�1lNAL RECORQ _ONf'JLE WI�I ;;' ,.`
<br />THE NEBRASKA HEALTH AND HUMAN SERI//CES SYSTEM, Y/TAL STAT/ST/CS �FLQl�f„INI��J IS ;;'
<br />THE LEQAL DEPOSITORY FOR VRAL RECORDS 1 _ °•
<br />DATE OF lSSUANCE , a.. �� � [ �� ►a � �`''
<br />N I I .,� � � w� fi , i .
<br />` . S C��f'�$�� �f ..1�� .
<br />,�28�2004 �osa�o��34 ���,�s��,��, ,, �.;
<br />UNCOLN, NEBRASKA HEALTHANA �SE�I���S�.Y , ; , . � . . ,
<br />, �, �a-- .��, , ,; ,� �.
<br />, -- . � _ - _ - r..��`.:_. �c-; �'�.'t _ rt - .
<br />� STATE OF NEBRASKA DEPARTNIENT OF HEALTH AND HUMAN SERVIC�FE�NC��YNDSI�PO�' ��� �� V� V�
<br />� VTfAL STATI3ITCS - � V !� �
<br />CERTIF'ICATE OF DEATH -°-�-.- �.., ._ „. ��
<br />, . .. --_ _ � - -- I I ,
<br />1. DECEDENT - NAME FlRST � b11DOLE �� LAST - 2. SEX , 3. DATE OF DEATH - lMontA. Day.� Yea�J
<br />Maxine Madl Peterson Female Dec 28, 2003
<br />4. CIiY AND 3TATE OF BIRTH ld rmt in U.SA. name couMry/ � Sa. AGE - I�at BINMay UNDER 7 YEAR UNDER 1 DAY 6 DATE OF BIflTH . lMOrd�. 0ay. YemJ
<br />� (Yrs) Sb MOS. OAYS 6e. HOURS' MWS.
<br />�Beadle County, South Dakota. 80 �� January 24, 1923
<br />�7. SOCU+L SECURTIY NUMBER� -� � Ba PLACE OF DEATH
<br />5 H�R^� � �c�a� oniea: ❑ Nursu+gHome
<br />Bb. FACILITY • Neme lBnof instllWon, glve streel ertd numbeil �� ��BN � Residence
<br />Howard County Community Hospital ❑ oon ❑ anarrs�,
<br />8c. CITY. TOVdN OR LOCATION OF DEATH - � Bd INS�DE�CIT7 LIMIT9 Be. CWNTY OF DEATH
<br />- - -_.�_ .-_ _.__-
<br />' S t . Pau1 - - - - -- � - v� � No � ^ Hoe�rarcl � - - - -
<br />8a RE8IDENCE-STATE � 96. CAUN7Y 9c. CITY.TOWNORLOCATION 8d. STREETAND�NUMBER pncludingZ/pCodeJ . 9e.INSIDECI7YUMITS
<br />Nebraska Hall Grand Island 619 W. llth St. 68801 r� � No ❑
<br />10. RACE - le.g., Whtte. Blacic. AmeHC� hfinen. 11. MICESTRY le.g_ Ileilan. Mexicen, Qertnan, e0¢) 72 a MARRIED ❑ VJ�DOWED 13. NAME OF SPOUSE (!f wils givemeMen namei
<br />�`��s White � Am.er3can N� DIVORCEO William Peterson
<br />14a USUALOCCUPATION (Oiveldr�dofwnrkdonedudngmcst �� 14b.•KINDOFBU3INE&$IN�USTRV ib. EDUCATION (Spacllyonlyhiglmstgradecompleted)
<br />_.
<br />__ ._...._.... _...._..._. . _ ....... ... ...._.__
<br />_ . ,. _.._ __... _.
<br />... . . . . ._ _ ., _ .__ _ . - - pementary m 9ecoqdap� 10-721 Caliege 11-0 a 5�1
<br />Hous � Domestic 1�
<br />18. FATHER-NAME -- . -- - FIR3T � MWDLE - -- LAST 17. MOTHFA � FlRST MIDDLE - - - MAIUENSURNAME -
<br />Bil Wi Lillian Rutterford �
<br />--- - --- ___ _ -
<br />1Q WAS DECEA'SED EVEA MU.S. ARMED FORCES? � ' 19alNFORMANT-NAME � � � . � � -
<br />nes. �w. o, �k.) nf,res. ¢�e ane amea m s�vrma) .
<br />No William Peterson
<br />18b. INFORMANT MNUN(i ADDRESS (STfiEET OR R.F.D. fd0. CI1Y OR TOWN. STATE ZIP� � � � � �
<br />619 W. 11th St., Grand Island, Nebraska 68801
<br />0. EM Efl - SIONATURE & LICENSE N0. � � 21a METHOD OF DISPOSITION 21b. DATE � 27c CEMETEflY OR CREMATORY NAME
<br />�� ❑��„�, Jan. 2, 2004 Westl.awn Memorial Park
<br />FUNERAL HOAf - NAME ' � " � . � �� � 21 d CEMETERY OR CREMATORY LOCATION CIN OR TOWN STATE
<br />Apf el-Butler-Geddes - ��`�"°" �� Grand Island, Nebraska
<br />22h. FUNERAL HOME ADDRE9S �STHEET OR R.F.D. N0. CITY OR TOWN. 3TATE, ZIPJ
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDUITE CAUSE �ENTER ONLY ONE CAUSE PER LINE FOH 1e61bj. ANO (c�� � Irrtarval behveen onset entl tleath
<br />j ''' 7 I
<br />PART � - -�� � Y .. �Is! /� � . ' .
<br />' �5 �'`�. f '
<br />tei � � � �
<br />� DUE T0. OR AS A CONSEOUENCE OK: . J . . . -- - .. . --� - - � - - - - - 1 Werval 6alween onaet arM deaN
<br />, 1
<br />. � ---- ' � --
<br />_ ��_ _ _ � C_!_'�'�'_��� ✓�__-_ .- -- . _` - � . 1 __ ' .
<br />DUE T0. OR AS A CONS€OUENCE OF: - - -. .-� - -- ----... _ I Irderval helween onset and deaN
<br />1
<br />1�I ' I
<br />P � OTHER� SIQWflCANT CONDi710NS - COnditlorre conUlbutlng to ihe death but rrot teleletl � PART III IF FEMALE WAS THERE A . 24 AUTOPSY 25. WAS CASE REFFARED TO MEDICAL
<br />p PREONANCY IN THE PAST 3 MONTHS7 �NFA OR CORONER?
<br />(Ages10-54) Yea No Yes No ' Yes No
<br />28a �. DATEOFWJURY /Mo..Oay.YiJ 2Bc. HOUROFIWURY 28d.0ESCRIBEHOWIWURYOCCURRm �
<br />� � AccideN � � Untletermined M - ' .
<br />� Suicfde � Pending 26e. INJURY AT WORK � 26t P�A�C F INJU�RY ��1t. homg, tartn, atreet.1ac10ry 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE �
<br />��Y/
<br />� Homfcttle Nvasagatlon Yes � No �
<br />27a DATE OF.D (R?a. Oay. YtJ , . . . . �� 28a DATE &IONED (Ma Dey. Ycl 286. � TIME OF DEA7H . .
<br />I �
<br />.S'� Y t � $tZ � M
<br />� 276. DA Nm (M Oay. Yr./ 27a TIME OF DFA7H �� y 2BC. PRONOUNCED DEAD /Ma. 0ay, Yr.l 28d PRONOUNCED DEAD (Hawl
<br />°' � t � �� ' .. � � DO . M � a � � M
<br />3� 27d To the �' ot 9a deatM rted et m& ar�d Placa end due tn the r �� 28e. Dn Me besla of examinatlon flnd�or irnestlgatlan, In my apinion deaih occimed et
<br />ceuselsl � � � cg � the tlme. date.a� P�e and due to 1he causals) sffied.
<br />-_ 'ISig erm 1 ► _ rt e �fSlg nmiue a TNaI ► � .
<br />28. OID TOBACCO USE CO�M ( E EATH? 30.a HAS ORGAN OA 173SUE DONATION BEQ�1 CANSIDERED7 3Q6 WAS CANSENT GRAN7E0? -
<br />, � YES � NO � UNKNOWN � YES . �GO � YES NO �
<br />- _---_-- -- - - - - - - .. .. _ . _
<br />81. NAWE AND ADDRESS OF CERTIFlEA IPHYS�CUW, COR6NER'S PHYStCVW OR COUNTY ATTORNEYI (TypeOrPdnl/
<br />Daniel P. Harr M .D. 1122 Rendall St., St Paul, NE 68873"
<br />-- -- - - - ----
<br />32a. REGISiRAR � � - � - � -- - - -�- - .. . - - - -- . / 32b. DATE FlLED BY RE6ISTRAR . /M2 0ay. Yr./
<br />--�.�s��i�� /1 I.�iffZ�Pn._ � ae��N ��� �D���nnn
<br />- -- EX[32aIT nAn � �e9e� -- e 4.e� � i cvu-r-
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