|
N
<br />2 SEX
<br />3
<br />3. DATE OF DEATH ;Mona, Day. Year)
<br />Freddie
<br />M.
<br />IN THE PAST 3 MONTHS'
<br />Dpr 2Q00__
<br />a CITY AND STATE OF BIRTH Ill not in US.A.. name counbvl
<br />_
<br />AGE - Last Bidhday
<br />UNDER I YEAR
<br />UNDER I DAY
<br />16 . DATE OF BIRTH )Monts Dav Vaarl
<br />C
<br />m
<br />N
<br />DAY S
<br />I
<br />Sc HOURS MINS
<br />May 14 19_1.1_____
<br />7 SOCIAL SECURITY NUMBER
<br />N
<br />8a. PLACE OF DEATH
<br />-
<br />Z
<br />Su -c,de Pending
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home
<br />- ---
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name At notinstitution, give street and number
<br />St. Francis Medical Center
<br />Hom�ctde Investigation
<br />❑ DOA ❑ Other ;Specd,,
<br />(�
<br />X
<br />1 80 INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH _
<br />�
<br />Yes _ No
<br />e
<br />Hall
<br />9a RESIDENCE -STATE
<br />' I
<br />r
<br />N
<br />T
<br />(n
<br />IN
<br />9e WSIDE CITY �IMl
<br />Nebraska
<br />Hall
<br />p
<br />O
<br />2211 N. Lafa ette 6 8
<br />Focl N °_�
<br />10 RACE - leg.. White Black. Amencan Intlian. I I ANCESTRY le q Italian. Mexican. German. etcl
<br />12 ® MARRIED
<br />❑ WIDOWED
<br />13 NAME OF SPOUSE W-1, grve..d,, name/
<br />etc) SbI0Vj White fSoecdyl
<br />YYYY1111 American
<br />� NEVER
<br />MARRI
<br />F -+
<br />111
<br />Kathryn �e7.��„eT,
<br />14a USUAL OCCUPATION /Gwe kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />°
<br />_
<br />15. EDUCATION (Specify only highest grade completedl
<br />t of working kfe. even d ri h edl
<br />2�d To the st of my knowledge. death o urred at the m ate and of can due to the
<br />28e On the basis of examination and or investigation. in my opinion death occurred at
<br />_
<br />Elementary or Secontlary IO 121 College I .
<br />Janitor
<br />2 =1
<br />N
<br />16 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />I7 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />O
<br />I7
<br />TH?
<br />Rebecca 11-Zli UNK
<br />O
<br />INFORMANT NAME
<br />�-IHASORGANORTIS'
<br />UNKNOWN
<br />,Yes nu or u,, I Ill yes. give war and dates of sere —sl YY YY
<br />❑ YES li-<O
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print,,
<br />Yes 09 14/42 - 12/27/45
<br />4)
<br />C
<br />32b DATE FILED BY REGISTRAR (Mo.. Day Yr./
<br />G O
<br />nr-n .1 n ►nnn
<br />N f
<br />202281
<br />�A - SIGNAT RE 8 LL E
<br />Q
<br />eQ,
<br />21c.
<br />O
<br />o
<br />] 1'
<br />CID
<br />Z:
<br />2000
<br />Westlawn Memorial Park
<br />22a UNERAL HOME NAME
<br />21d CEMETERY
<br />OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kl ine Funeral Home
<br />rn
<br />Grand Island Nebraska
<br />D
<br />~
<br />3213 W. North Front Street, Grand Island, Nebraska
<br />68803
<br />"T
<br />o
<br />o
<br />d
<br />o
<br />N
<br />ca
<br />rn
<br />ca
<br />CA
<br />C.3
<br />(A
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIQ@hAt_l&ZQRD_ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 7,"' C$,SeCTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -..
<br />DATE OF ISSUANCE
<br />200107963
<br />-- BLEY S COOPER
<br />DEC 9 ZOOO
<br />ASSISTANT STATEREGISTRAR
<br />LINCOLN, NEBRASKA HEAL ?WAND HUMAN SERWICESSYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTIi'AND HUMAN-SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH'
<br />I DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3
<br />3. DATE OF DEATH ;Mona, Day. Year)
<br />Freddie
<br />M.
<br />IN THE PAST 3 MONTHS'
<br />Dpr 2Q00__
<br />a CITY AND STATE OF BIRTH Ill not in US.A.. name counbvl
<br />_
<br />AGE - Last Bidhday
<br />UNDER I YEAR
<br />UNDER I DAY
<br />16 . DATE OF BIRTH )Monts Dav Vaarl
<br />New York City, New York
<br />26c HOUR OF INJURY
<br />11,
<br />IVrs I
<br />89
<br />DAY S
<br />I
<br />Sc HOURS MINS
<br />May 14 19_1.1_____
<br />7 SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />-
<br />• 101 -10 -8468
<br />Su -c,de Pending
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home
<br />- ---
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name At notinstitution, give street and number
<br />St. Francis Medical Center
<br />Hom�ctde Investigation
<br />❑ DOA ❑ Other ;Specd,,
<br />Sc CITY TOWN OR LOCATION OF DEATH
<br />1 80 INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH _
<br />Grand Island
<br />Yes _ No
<br />I
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b COUNTY
<br />r
<br />9c CITY TOWN OR LOCATION
<br />94. STREET AND NUMBER llncludrng Zip Code)
<br />IN
<br />9e WSIDE CITY �IMl
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2211 N. Lafa ette 6 8
<br />Focl N °_�
<br />10 RACE - leg.. White Black. Amencan Intlian. I I ANCESTRY le q Italian. Mexican. German. etcl
<br />12 ® MARRIED
<br />❑ WIDOWED
<br />13 NAME OF SPOUSE W-1, grve..d,, name/
<br />etc) SbI0Vj White fSoecdyl
<br />YYYY1111 American
<br />� NEVER
<br />MARRI
<br />DIVORCED
<br />1
<br />111
<br />Kathryn �e7.��„eT,
<br />14a USUAL OCCUPATION /Gwe kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />°
<br />_
<br />15. EDUCATION (Specify only highest grade completedl
<br />t of working kfe. even d ri h edl
<br />2�d To the st of my knowledge. death o urred at the m ate and of can due to the
<br />28e On the basis of examination and or investigation. in my opinion death occurred at
<br />_
<br />Elementary or Secontlary IO 121 College I .
<br />Janitor
<br />Maintenan
<br />► cause(s) stated.
<br />16 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />I7 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Imorris NMI
<br />Kati
<br />TH?
<br />Rebecca 11-Zli UNK
<br />IS WAS DECEASED EVER IN US. ARMED FORCES' c.R
<br />it -19a
<br />INFORMANT NAME
<br />�-IHASORGANORTIS'
<br />UNKNOWN
<br />,Yes nu or u,, I Ill yes. give war and dates of sere —sl YY YY
<br />❑ YES li-<O
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print,,
<br />Yes 09 14/42 - 12/27/45
<br />Kathryn Katz
<br />32b DATE FILED BY REGISTRAR (Mo.. Day Yr./
<br />19b INFORMANT MAILING ADDRESS iSTREET OR R F D NO.I CITY OR TOWN. STATE ZIPI
<br />nr-n .1 n ►nnn
<br />N f
<br />202281
<br />�A - SIGNAT RE 8 LL E
<br />21'a METHOD OF DISPOSITION
<br />21b ATE
<br />21c.
<br />CEMETERY OR CREMATORY NAME Cemetery
<br />] 1'
<br />°r ❑
<br />B al Remo —1
<br />Dec. 12
<br />2000
<br />Westlawn Memorial Park
<br />22a UNERAL HOME NAME
<br />21d CEMETERY
<br />OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kl ine Funeral Home
<br />❑ Crema " °" ❑ ° °na " °"
<br />Grand Island Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F D NO CITY OR TOWN.
<br />STATE, ZIP(
<br />3213 W. North Front Street, Grand Island, Nebraska
<br />68803
<br />Ld. 1 t UAUSt
<br />1 '
<br />PART
<br />S 1
<br />lal
<br />AS A
<br />llY J
<br />4SEQUENCE OF
<br />Ibl �N e A) fy-eryY1 ir�_
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />IcI �. f'\r ( `AMVr
<br />(ENTER ONLY ONE CAUSE PER LINE FOH ial Ib) . AND ICI(
<br />Interval between onset -t- --
<br />Trnr» e ,lA,i
<br />Interval `between onset ann oealr
<br />Interval between onset
<br />) Mn
<br />OTHER SIGNIFICANT CONDI NS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />X AUTOPSY
<br />MAL
<br />2(I WAS CASE REFERRED TO EDIC
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS'
<br />EXAMINER OR CORONER"
<br />0
<br />(Ages 1541 Yes No
<br />Yes No
<br />Yes F No
<br />26a
<br />26b DATE OF INJURY (Mo.. Day Yr/
<br />26c HOUR OF INJURY
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />C� Accident Undetermined
<br />M
<br />Su -c,de Pending
<br />26e. INJURY AT WORK
<br />261 PLACE OF INJURY - AI home (arm street. factory
<br />26q. LOCATION STREET OR R F D. NO CI I Y OR TOWN— Crr. •
<br />Hom�ctde Investigation
<br />Yes No
<br />❑ ❑
<br />office budding. etc rSoedfyl
<br />27a DATE OF DEATH /Mo.. Day. Yr.)
<br />1 28a DATE SIGNED (Mo.. Day. Y,)
<br />-
<br />28b TIME OF DEATH
<br />r
<br />December 8,2000
<br />$
<br />$ i a y
<br />M
<br />27b DATE SIGNED (MO. Day Vr 1 c TIME OF DEATH
<br />28c PRONOUNCED DEAD IMo. Day, Yrl
<br />_
<br />28tl. PRONOUNCED DEAD (Hour
<br />J
<br />N
<br />o
<br />g F
<br />emO M
<br />°
<br />2�d To the st of my knowledge. death o urred at the m ate and of can due to the
<br />28e On the basis of examination and or investigation. in my opinion death occurred at
<br />a
<br />° v
<br />► cause(s) stated.
<br />° '
<br />' me ume. date and place and due to the cause(s) stated .
<br />lSi nature and Tall
<br />iSi nature and Title 1,
<br />DID TOBACCO USE CONTRIBUTE TO THE E
<br />TH?
<br />UE DONATION BEEN CONSIDERED>
<br />30N WAS CONSENT GRANTED'
<br />❑ YES N0
<br />�-IHASORGANORTIS'
<br />UNKNOWN
<br />YES 0
<br />❑ YES li-<O
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or Print,,
<br />lRyan D. Crouch MD 00 N. 41plia Street, Grand
<br />32a REGISTRAR ''�
<br />32b DATE FILED BY REGISTRAR (Mo.. Day Yr./
<br />T ,".. . ,
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