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Rey. 1+94 STATE OF NEBRASKA-DEPARTMENT OF HEALTH <br /> BUREAU OF VITAL STATISTICS <br /> . CERTIFICATE OF DEATH ;_ 98- 1��a�6S4 <br /> 1.DECEDENT-NAME FIRST MIDDLE LAST 2.SEX ''�3 DATE OP DEAtH �MOnin.Day.Vearl <br /> Male Ma 8, 1996 <br /> 4.CITV AND STATE OF BIRiH /Nrrol in US.A..name counfry) Sa.AGE-Last Birihday UNDER 7 VEAR UNDER 1 DAY 6.DATE OF�.BIRTH iMOnlh Da�.Yearl <br /> (Vrs.l Sb.MOS. DAYS Sc.HOURS' MINS. <br /> Kennard Nebraska 63 � June 5 1932 <br /> 7.SOCIAL SECURTIV NUMBER 8a.PLACE OF DEATH <br /> HOSPITAL: � Inpa�ien� OTHER�. � Nurs�nq Home <br /> ' 505-34-4766 - <br /> 8b.F ACILRV-Name /n nof mshtufion,grve slree!and numbei/ � EP Oulpa�ient � Resitlence <br /> . <br /> 4 318 Ma r i a n R d. � 6 8 8 0 3 ❑ °OA � ome�isPe����,-_ <br /> Bc CITV.TOWN OR LOCATION OF DEATH 8d.INSIDE CITY LIMITS Be COUNTY OF DEATH <br /> Grand Island ves � "° ❑ Hall Count <br /> 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY,TOWN OR LOCATION 9d.STREET AND NUMBEF /lncludingZip Codel 9e INSIDE CITV LIMITS � <br /> Nebraska Hall Grand Island 4318 Marian Rd. , 68803 ves 0 "o❑ <br /> 10.RACE-�e.g.,While.Black.American Intlian. 11.ANCESTRV�e.g..%alian,MeKican.Caerman,elci 12.�MARRIED ❑WIDOWED 13.NAME OF SPOUSE !l7 wrle.gne maiden name) <br /> e1cllSpecity� (Specity� NEVER DIVORCED <br /> a� White Norweign <br /> 0 �MARRIED Retta McAtee <br /> 1Aa.USUALOCCUPATION (CrvekiMolworkAonedurirgmosl tAb.KINOOFBUSINESSINDUSiRY 15.EOUCATION �Specdyonlyhigheslgratlecompleted� <br /> O d Hx��k�ng/Ae,even ArenrMl Elementary or Secondary 10�12� Colleqe I1-a o�5�i <br /> � Civil En ineer United States Air Force 12th Grade <br /> C 16.FATHER-NAME FIRST MIDDLE LAST V.MOIHER FliiS7 MiDULE MAIDENSURNAME � <br /> O • <br /> ° - Oscar NMI Andrews Dec. Irene NMI Brice Dec. <br /> O ' 18.WAS DECEASED EVERIN US.ARMED FORCES? 19a.WFORMANT-NAME <br /> `y Ives.no.or unk.� pl yes.give war and dates o(services� <br /> `- Yes Korea 7 1 52 to 6 10 54 Retta Andrews <br /> � 19b.INFORMANT MAILING ADDRESS ISTREET OR R.F.D.NO.,CITY OR TOWN.STATE ZIP� <br /> X <br /> °' 4318 Marian Rd Grand Island Nebraska 68803 <br /> � 20.EMBA MEFi-SIGNA7URESLICENSE O. 21a.METHODOFDISPOSITION 21b.DATE 21c CEMETERVOFCREMATORV NAME <br /> U <br /> � � � <br /> �z � ' � �/U3 ❑X e���a� �Removal May 11, 1996 Parkview Cemetery <br /> Q 2 PUNERAL HOME-NAME 27d.CEMETERV OR CREMATORV LOCA710N CRV OR TOWN STATE <br /> U :� Kleine Funeral Home �Cremafion ❑o�,a��o� Hastin�s, Nebraska <br /> WQ L 22b.FUNERAL HOME ADDRESS �STREET OR R.F.D.NO..C�TV OR TOWN,STATE,21P� <br /> � a 3213 W. North Front St. , Grand Island, Nebraska 68803 <br /> O � 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR IaL Ib�,AND�cp I Inlerval behveen onse�and tlealn <br /> � m <br /> 7 PAR'aI Cardiac Event � Unknown <br /> Q � _ <br /> Z LL �UE TO,OR AS A CONSEOUENCE OF I Inlerval Aelween onsel anA tleath <br /> i <br /> i <br /> M @I i <br /> M DUE TO.OR AS A CONSEOUENCE OF: I Inlerval between onset antl tleatn <br /> i <br /> I <br /> ��� I <br /> OTHER SIGNIFICANT CONDITIONS-Conditions coNributing to the dealh but no�relaled PAR7 III IF FEMALE.WAS 7HERE A 2a AUTOPSV 25.WAS CASE REFERRED TO MEDICAL <br /> PART PREGNANCY IN THE PAST 3 MONTHS? EXAMWER OR CORONER� <br /> '� Emphysema <br /> �Ages 10-54� Ves No Ves No � Ve5 No <br /> 26a 26b.DATE OF INJURV /MO..Day.Yc/ 26c.HOUR OF INJURV 26d.DESCRIBE HOW INJURV OCCURRED <br /> � Accident � Undelermined M <br /> � Suicide � Pending 26e.INJURV AT WORK 261.PLACE QF.INJURV-At home.farm,slreel.factay 26g.LOCATION STREET OR RFD.NO. CITV OR iOWN STATE <br /> ❑ ❑ ❑ oBice bwldmg,etc. (Speci/y) <br /> Homiclde Invest�qation Ves No <br /> 27a.DA1E OF OEATH (MO.Day Yr./ 28a.DATE SIGNED /Mo..Day.Yr.� 28b TIME OF DEATH <br /> 'U n�z �� / " �� ��QngM <br /> -- �� 27b.DA7E StGNED /MO..Day Yr/ 27c.71ME OF DEATH �i� 2BC.PRONOUNCED DEAD /MO.Day.Yr1 28. PONOUNGE DEAD /HOUrI <br /> aaa� p O <br /> �g'° M 8�i�o 5-�-96 O ; �F V 3M <br /> � °� 27d.To Ihe best W my knowledge.death occurred at ihe time,dale and place aM due to the °a°° 28e.On the basis ol eraminatwn and� r inveslig � my oplrn de wrred at <br /> causels�stated. ~° � Ihe lime,date and place ana 1 the c tat � <br /> (Si naWre and iitle)► (Si naWre and Title► <br /> 29 DID TOBACCO USE CONTRIBUTE TO 1HE DEATH? 30.a HAS ORGAN OR TISSUE DONAiION BEEN CONSIDEqED7 30.b WAS CONSENT RANTED� <br /> � YES � NO � UNKNOWN � YES � NO VES � NO <br /> 31.NAME AND ADDRESS OF CEATIFIER IPHVSICIAN,CORONERB PHYSICIAN OF COUNTY ATTORNEY) /Type a Prinl/ <br /> Lt . B. Brush Grand Island Police De <br /> 32a.REGISTRAR 32b.DATE FILED BY REGIS7RAR /Mo.Day.Yr/ <br /> C <br /> �°`� /a, �, ��� <br /> FOR VITAL STATISTICS USE ONLY <br /> Place.......................A................................B................................C................................D................................E................................Part II......................TMV........................... <br /> NSC...................................................................................:...............................................................................................................................................................Census Tract No. <br /> Work.......................................................................................................................................................................................................................................................................................... <br /> UC.......................................................................................................................................................................................................................................................... <br /> Reject.................................................................................................................................................................................................................................................. <br /> �Prinled+rll�soY Ink on ncYeNA psper� � <br />