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WHEN 1}NS COPYCARliJE3 TI£RAISEO SEAL OF THE NEBRASIG4 HEALTH AND HU�iAN SERNCES SYSTEA�,IT CERT�IES TF�BELOW TO BE A TRUE COPY OF THE OWQ/NAL ItECORD ON FJLE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEII�VITAL STATf3TICS SECTIOIIti WHICH/.4 s , THE LEOAL DEPOSITORYFOR VITAL RECORD� , � DATE OF 13SUANCE � � �� 3 0 �ssa ANLEY�COOPER A3SISTAIVT 3TATE RE013TRAR , �� HEALTHAND HUMANSERVECE3 SYSTEM 90� 1Cl'31�U r�aiusx�-uEr�nnr�rrr oF�trH�xn xu�w+rr sExv�cBS��rrce�rm surroRr V1TAI.STAIISTICS CERTIFICATE OF DEATH � �.DECEDENT.NAAAE iIRST MiOpLE UST 2.$EX 1 OATE OF OEATM /MprNn.qry.YNy �� 'Frederick Head Male March 23 1998 . �.dT�ANO STATE OF&i1TM /I nof n U S A..n�rn�eouryyl Sa.AOE•lap 6ireq�y VNOER 1 YEAq UNDER t OAY 0.OATE OF&RT11 IMpN�t p��,rNy Dodge County, NebZ'dSkd �v,•� �6 se �.ros wrs so.HouAS� �+s. . �.socu�secunm Nur�eea Md 15 19 21 e..Puce oF o�rH � 5�8�18-18$'� 1qSPITAL: � MpaOMN OTHER�. a NvfrqMOny l0.fACNJTY•Nam� /Nnpnyq�ypqp;�„��y�Mp�,,�p�y � EpO�p�Y�M � q�� . Br an Memorial Hos ital ❑ �� ❑ o�.,,��., !G CtTY.iOWN OR LOCATION Of OEATM !0.INSIOE pTY UMITS !l COUNTY Of DEATM L inco].rl �� ❑ Lancaster ia RE&OENCE•SiATE YD.COUNTY pe.CITY.TOWN Qq IOCATION YQ$TREET ANO NUMBER /htle�qNp j�p(`,p,yr/ y�IN$�pE p}y IMpTS Nebraska Hall Grand Island � 116 E. Ashton 68801 �«� �❑ �0.n�CE•N.q.w�wa l4ck.�nw¢�n Man. ��.M�CESTRr i�q_�win+.AN.�can 6�m�n.Ncl u.�ruwwED ❑v�nooweo �a wu�[oF srousE rr w�►.a�+�aM�wnq .��e.�� ISo�eayl WLll e AjnQY'iC3I1 NEVER DtvOACED Joan ��11 1ta USUALOCCU7ATpN lGnrhnOWror4dpr»qplrqnqp 110 KINOOFBUSINESSINOUSTRV 15.EOUCATION �Sp�tdy ��pTpy�b� wOnFM19 NN.IYM M�IM107 � � , S tion Agent Frontier Airlines E'"�'�"''"�"oi0iry10''�' °aMiqi'�'°'''' 16.FATMER�NAME fpSi MIDDIE UST /1 MOTMER FIRST MIDOIE MAIDEN$URNAME ' Daniel Head Edith Holbrook 1!.WAS OECEASEO EVER IN U.S.ARMED FONCES? t9a INFQRMANT.NAME �es«�`� �W4�I��=�1 r4r43�'�0 2/16/46 Joan Head 19p INFORMANT M�ILINO AppRESS ISTREET OR F i D NO..GTV ON ipWN.STATE.21P� — 116 East Ashton Grand Island, NE 68801 IO EMBAL ER-SqNATUAE 6 UCENSE 21 a.METN00 pF qSPOSitipN 210.DATE t1C.CEMETERY OR CREMATOaY NAME . � �a�� ❑�.�,.� March 27, 1998 Hoo Cemet �.FUNEML HOME•NAME 21E CEMETERV Qp CREMATpRV IOCATpN Clir pR TOWN STATE A fel-Butler-Geddes F.H. ❑Cnmapon �o,,,,,� � Hao NE 22p.fUNERAI HOME ApOqESS ISTpEET Qq RF.O.NO..CITY OR TOWN.STATE.21P� 1123 West Second St. Grand Island I� 68 0 - IMMEDIATE CAUSE IENiER ON�V ONE CAUSE PEA LINE FOA 41.IbG AND�C�I � PART ' �.� �'8 R.7 I� (l� P 1 N r1�� I ��.��».��.�a.�� � � OUE TO.OR A$A CONSEOUENCE OF i � ImVrai wnw�n onsn�n0 O�am �e� �.�C v�n.n Fa�✓1 �R 7 i e �S e.�S i � � DUE TO.Wi AS A CONSEOUENCE Of� � . 1 NMMVaI W W�M10MM YM O�iN f�' 1 I OTMER SIGNIFICANT CONDITpNS.(',pnpi�pns 1 VAqT ��9 a me Csam dn nd rNaiW PqqT III IF FEMALE.WAS THERE A t� AUTOPSY ZS.WAS CASE REFEqRED TO MEOICAI II PREGNANCV IN THE PAST J MqVTH$� E7(AMINER Oq CORONERi IAqa�0•Sal va rb rn No vp Hp M� 1C0.OATE OF IWURV /M0.DIY.Y�.1 26t MOUR OF INJURY 2!Q DESCRIBE 110W iNJUM OCCURRED � AttMeM � IMWIMmKNC � \ � SuKiA� 0 M ❑ �^9 2Et iNJURV A7 WQRK tM PU:E .iNJ�V% 1q, .yrm.7rc�.4e1pry 29q,LpCATpN SiREET ON 0.F.D.N0. CITV OR TpWN STATE � ❑ Morniei0� htiafl,y�uy� ��❑ �❑ aMe 27a DATE OF OEATN /Ma.Wr.y�.l Zea.D�tE SIGNED qb_D�r v.l 2e0 inaE OP DEAiN � a� MdrCh ?3 1998 a�� �t DAT%$IpNED`/MO Osy.n/ 27a TIME Of pEATM k„ �.PRONpWdCED OEAD /Ab..D�y,Yr/ 2!d PRpNq/r�EO OEAO /M�vl M -�� 3 /LS (°+'6 M ��`� n 4:05 e.ro m.e.a a mr w e. u �a u,e a+e.w aw a aw �� M uu�u aawa e ze�.On m�euis w�iam++aian ane�«hv��epuion.in mr owwn aan aaw.�a u e»w�..aaN.na a�e•w aw a m.eww�n nwa. � .w.w rm�► ao roe�cco use coarn�eure To n,e o�n�v ".a„•,�a rA. . NAS OROAN OR nSSUE OOw1T1pN BEEN CONSIDEREO'+ WAS CqNgENT pRANTEO'+ � � YES � NO � UNKNOWN � YES � NO � �j �Y� . � VES (� Np 3/ NAME ANO AODRESS OF CERTfIEA�pMYSI(`,1Al1,(�qpNER'S PMVSICIAN OR CQ�NTV ATTONNEY� lTyp plipiry Mark G. Griffin MD 1500 So. 48th, Suite 712, Lincoln NE 58506 32a.AEGISTRAq ��A'A�/��O� J20 OATE FILED 8V REGISTMq /81p.,p�y,Yt/ �� ia�, 3 0 1998