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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE`~NEBRASKA STATE 2 0 1 2 0 2 2 4 7
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW, T BE A TRUE'COPY.,
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE'DPARTT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL= _9_8_I_TORY FOR
<br />VITAL RECORDS. =`g-
<br />DATE
<br />~~pp~Oy® OF ISSUANCE
<br />tl~~ F~ ST NT - , - rto ERECTOR . _
<br />LINCOLN, NEBRASKA BUI -0_VTAI~ _BTOISTICS
<br />v mgd
<br />Pid `
<br />es' 4 1992 STATE OF NEBRASKA - DEPARTIIAENT OF HE1LLTIi µ
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ~ } on
<br />1. DECEDENT - NAM FIRST MIDDLE LAST
<br />2. SEX 3. DATE of DEATH / ftft Dry, Ye"
<br />Sylvanus John Happ
<br />Male September 29, 1992
<br />4. CITY AND STATE OF S.RTH 9 not fn U.SA, steep omudW Ss AGE - Laat Bn ftd,y
<br />S. DATE OF SIRTH iMIMr. Dry, YW
<br />Lindsey,} Nebraska (Yna) -7$ UL mos. DAVS
<br />fie MINA I HOURS i Aril 9 1921
<br />7. SOCIAL SECURITY 1 Ba. PLACE OF DEATH
<br />oERI o DOA
<br />501 18 591
<br />a - , mom. 0 Residence o Offm JAWOW1
<br />Bla, FACILITY - None J prof fteLCmL OW -1 I and naW
<br />Ba CRY. TOWN OR LOCATION OF MATH w INSIDE OF LIMITS Bs. CouNTY OF MTN
<br />(Spw* Y® a Nat
<br />ra"for
<br />Grand Island Yes Hall
<br />IL fTE~DENCE • STA
<br />83 COUNTY Bo. CRY, TOWN OR LOCATION
<br />Bd STREET AND NUMBER fbidu l ny UP lady
<br />Be. INSIDE CITY LIMITS
<br />(Sopm* Yn w NO)
<br />Nebraska'
<br />Hall Grand Island
<br />1708 West Division
<br />1a RAGE -lap, WNb, Si,elr. Anwyaat IrkOyn,
<br />11. ANCESTRY (a2.,haean. tiatdean, Gamisrt, eb.) 12. MARRIED.NEYER MARRIED.
<br />13. yAM
<br />e SPOj~E JIlj~/h, pWS maiden name)
<br />afa) fly) White
<br />(Sptelr) German t O _ WIDOWED. ed ° (SPOW
<br />~
<br />A s ~etr
<br />14a USUAL OCCUPATION (Q(n AM of Work daf
<br />t drokq moat
<br />14b. KIND OF BUS NESS INDUSTRY
<br />orWorkh INC
<br />a
<br />d lr
<br />er
<br />l
<br />(
<br />'
<br />(0.12) I CSRept (1.4 or S•)
<br />Memamar
<br />or Secondar
<br />A
<br />ta
<br />s
<br />s
<br />,
<br />3
<br />B
<br />~
<br />t
<br />d
<br />UAI
<br />y
<br />y
<br />'
<br />ar
<br />en
<br />er
<br />Tavern
<br />8th Grade
<br />1B. FATHER -NAME FIRST YfDOLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />(dec.) Edward Happ
<br />Albracht
<br />(dec.) Dorothy - lbreeb -
<br />18. WAS DECEASED EVER IN U.S. ARMED FORGET?
<br />18. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN, STATE. ZIP)
<br />T ro, orlaic) lI ysa mar and dabs of M VIM)
<br />WWII~3
<br />1
<br />1
<br />eB
<br />s
<br />-
<br />3-43/
<br />0-23-45
<br />Happ, 1708 W. Division, Grand Island NE
<br />as. BURIAL, Oramadon,Rstddvaf, 200. GATE
<br />fi
<br />A
<br />20a. CEMETERY OR CREMATORY - NAME
<br />Wd. LOCATION CRY OR TOWN STATE
<br />r
<br />t
<br />B rial' 10/3/1992
<br />Sacred Heart Cemetery
<br />Greeley, NE 68842
<br />M. EUBAIAIJEW- SIDNATUREe SEJNO: w i
<br />0- FUNERAL HOME - NAME AND ADDRESS IS
<br />TREET OR R.F.D. NO- CRY OR TOWN. STATE. ZIP)
<br />T. J. Finn & Sons Greeley, NE 68842
<br />9. IA; (ENTER ONLY ONE CAUSE PER LINE FOR (sb (b). AND (c)) i bderval behreert anmf and death
<br />Co eFailure '2 hours
<br />DUE TO. OR AS A CONSEQUENCE OR I (mewl belvree, onset and death
<br />Cardiac Valvular Disease '1 year
<br />DUE TO. OR AS A CONSEQUENCE OF: I bftmW between onset and dealt
<br />I
<br />Coronary Arterv Disease unra rt,an q vumra
<br />OTHER SIGNIFICANT CONDITIONS - CondiSors.oontri adirq to deaM DN not related
<br />PART 111 0: FEMALE, WAS THERE A
<br />24.
<br />2a. WAS CASE REFERRED TO MEDICAL
<br />P~ _
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />w W,
<br />.
<br />EXAMINER OR CORONER?
<br />Carcinoma Prostate
<br />Yea 0 No ❑
<br />No
<br />(SpcayYesorAb)No
<br />28a ACCIDENT, SUICIDE, HOMICIDE, UNDET,
<br />2130. DATE OF INJURY WaAq, Yr.)
<br />26c. HOUR OF INJURY
<br />28d DESCRISE HOW INJURY OCCURRED
<br />OR PENDING INYEBTIOATION (Spf^
<br />1
<br />1
<br />28a INJURY AT WORK
<br />2111. PLACE OF INJURY - At harry turn, easel factory,
<br />24 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(Speey Yee or Nat
<br />amts b dk%m, et. (spa*)
<br />27a DATE OF DEATH (W 00,, Yr.)
<br />2Ba DATE SIGNED (MO, Day. Yr.)
<br />2130. TIME OF DEATH
<br />a
<br />September 29, 1992
<br />a
<br />270. DATE SINNED (Ma, Dar Yr.)
<br />27a TIME OF DEATH
<br />no. PRONOUNCED DEAD (eb., Day. Yr.)
<br />nd. PRONOUNCED DEAD (Flouq
<br />October 3, 1992
<br />10.15
<br /><
<br />3
<br />P"
<br />27d To this best of my lmaded2e, pyq and doe So
<br />caws(s) staked. /1
<br />B g
<br />$ b
<br />2B9. On the bass of examination and/or inveteipt on, in my opinion death occurred al
<br />the bins. date and place and due to the cause(s) elated.
<br />and Tay '
<br />01,
<br />(tsiciftaim and Tss
<br />29L DID TOBACCO USE CONTRIBUTE TO
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />O YES RNO O UNKNOWN
<br />7 O YES
<br />IRNO
<br />0 YES NO
<br />Muwuuarcaa vcnrrncn lrn.oRi+u4 wrwmcna rnrWRiwn ~n .:vuniT nrrvnn¢.t lryosw~
<br />Bobby Abra i M.D.,#VA,Mdical Center, 2201 N. Broadwell. Grand Tc1and_ NF. 68803
<br />~ (~1• OCT 1402
<br />
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