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T M 4 <br />z n = <br />n n o rn <br />M D C") co �• <br />oD <br />x m <br />O � <br />Tj N <br />I <br />3 <br />W <br />_,.� <br />C-1 z <br />\' w <br />\ W O Z <br />n N O <br />O <br />O N �+ <br />f� <br />1 <br />O <br />WHEN THIS COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTHAND HLMIN SERVICES <br />SYSTEP4 IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-QAEEl f WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS,�DF IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = <br />DATE OF ISSUANCE - - <br />p021 ANLEY <br />7/7/2003 20031 ASSISTANT <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES .SYSm� <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEILVJCEB'F0 hND7SU 1YRT <br />VITAL STATISTICS _ 3 0 7 4 3 2 <br />rF F LT .RTTFTrAT OF T)FAT _ .._ <br />r- <br />0 <br />N <br />0 <br />n <br />� J <br />r' <br />n <br />4N <br />N (G� <br />O. <br />Q f <br />n_ <br />o' <br />O <br />CD <br />0 <br />1 <br />O <br />h <br />VJ <br />CL <br />L <br />O <br />C <br />`< <br />Z <br />CD <br />Cr <br />Tv <br />>y <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX , <br />3. DATE OF DEATH (Month. Day. Year) <br />Ramona Joanne Cox <br />Female <br />June 29, 2003 <br />4. CITY AND STATE OF BIRTH Iermtkr USA.. name counsyl <br />Sa. AGE -Last Birthday <br />UNDER 1 YEAR <br />UNDER t DAY <br />6. DATE OF BIRTH IMOnM. Day. Year! <br />Sb. MOS. DAYS <br />5c. HOURS' MINS. <br />Grand Island, Nebraska <br />(Yrs.) <br />74 <br />July 19, 1928 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PUCE OF DEATH <br />HOSPITAL ® Inpatient OTHER: 11 Nursing Home <br />R AS A CONSEQUENCE OF .. Interval onset and death <br />506 -28 -7176 <br />❑ ER Outpatient Residence <br />8b. FACILITY - Name (//not insMulpn, give street and number) <br />St. Francis Medical Center <br />❑ ODA ❑ Oth8f (Spec N' <br />Bd. CITY. TDWN OR LOCATION OF DEATH <br />Sd. - INSIDE CITY LIMITS <br />as. COUNTY OF DEATH - <br />Grande island, Nebraska <br />Yes © No ❑ <br />Hall <br />91L RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including ZP Code) <br />9e. INSIDE CITY LIMITS <br />26b. DATE OF INJURY (Mo.. Day. Yr,1 <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />1113 <br />Yes ® No ❑ <br />Nebraska <br />Hall <br />Grand Island <br />West 21st Str,68801 <br />26f. PLACE OF i INJURY �At h�, farm. street. factory <br />oMllBCCee Spec <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY leg.. Ulan. Mexican. German, etc) <br />12. -® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE #1 wife. give maiden name) <br />etc./ (Specify) <br />ISpecllyl <br />I /En lash <br />NEVER DIVORCED <br />Clarence B. Cox, Jr. <br />White <br />Irish <br />MA <br />9! <br />14a. USUAL OCCUPATION /Give klrtd o( avrk atone durgrg mast <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Samentarygr�econdary l0 -12) College 11 -4 of 5 -1 <br />of working lffe, even Nrefired) <br />27c. TIME OF DEATH <br />- Homemaker <br />Domestic <br />lL <br />16. FATHER - NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />117 <br />Arthur Sanders <br />Violet Reed <br />1& WAS DECEASED EVER IN U.S. ARMED FORCES? <br />' 9a. INFORMANT - NAME <br />(Yes. no. or unk.) (I yes. give war and dates of servicesl <br />Clarence B. Cox, Jr. <br />no <br />ii <br />19b. INFORMANT MAILINU AUUMCJJ w <br />20. EMBALMER - SIGNATURE 8 LICENSE NO.` <br />21a METHOD OF DISPOSITION <br />210. DATE <br />21 c. CEMETERY OR CREMATORY NAME <br />riot Em alined` - <br />❑ Buda) ❑ Removal <br />June 29, 2003 <br />Central Nebraska Cremator <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Geddes <br />GaGemitim Donator, <br />Gibbon, Nebraska <br />E ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE 7JPI <br />est Second Street, Grand Island, Nebraska 68801 <br />PButler- <br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Cal. (bl, AND (c)) I Interval between onset and death <br />R AS A CONSEQUENCE OF .. Interval onset and death <br />fbf <br />R AS A CONSEQUENCE OF: I Interval between onset and death <br />I <br />Icl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />I <br />(Ages <br />70 -54) Ves No X <br />Yes No <br />Yes No Ln <br />ML <br />26b. DATE OF INJURY (Mo.. Day. Yr,1 <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Aoei/wIl Undetermined <br />M <br />Suicide Pentling <br />26e. INJURY AT WORK <br />26f. PLACE OF i INJURY �At h�, farm. street. factory <br />oMllBCCee Spec <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes E], No ❑ <br />. <br />27a DATE OF DEATH Day. Yr. " <br />IMQ• <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />28b TIME OF DEATH <br />9! <br />Y <br />`is' g <br />27b. DATE SIGNED lMa. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.). <br />28d. PRONOUNCED DEAD /Four! <br />K` <br />M <br />Ez <br />I <br />27d. To the best ol my knoWa"e. dean at the time, date and place and due to the <br />28e. On Me basis of examination and,or investigation, in my opinion death occurred at <br />ii <br />.2 o <br />6 <br />cause(sl stated. w _ <br />!1 <br />c <br />the time, date and place and due to the causels) stated. <br />(Signature and Tide / <br />fsi nature and Title) <br />2, . DID TOBACCO USE CONTRIB DEATH? 30.a <br />HA ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES ❑ NO " PO LINIQJOWN <br />-- "'IAN, <br />_ ❑ YES X NO <br />❑ YES NO <br />r. NAME AND ADDRESS OF CERTIFIER (PHY/SSIC� CORONER'S PHVSCIAN OR COUNTY ATTORNEY) (Type or Pnmf <br />Dr. Jeff King, 729 orth Cu ter, Grand Island, Nebra ka 6880 <br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR (MO_ Day. Yr.) <br />JUL - 3 2003 <br />fill- <br />