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WHEN THIS COPYCi4RR/ES THE RA/SED SEAL OF THE NEBRASKA HEALTH AND HU aM. u►-SERV/CES '- SYSTEM, IT CFRT/FlES THE BELOW TO BE A'�tUE COPY OF THE OR/G/NAL RE�9N��AIJTFI �;� THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, V1TAL STAT/S'��CTf�r�NHlCFfJS' THE LEOAL DEPOS/TORY FOR V/TAL RECORDS _ " � DATE OF /SSUANCE � - - � �''�` �0 � � ; ; APR 11 200Z 2 012 0 3 4 5 ti as�r,� sr,�T �� s�� LINCOLN, NEBRASKA HEALTH AND Ht�JNA11E SF�1%/C�� S�STE,� . STATE OF NESRASKA- DEPAR'fN�lV'f OF HF.ALTH AND HUMAN S�RVICES FfNA-A[GE AND SlJgl'VRT _ . CE RTI CATE OF DEATH =_. .- -' � � :. Q'`� � � `� 1. DECEDENT - NAME FlRST MIDDLE LAST 2, SEX � _,�ATE OF qEATH� /MOrtth._DpY Ye8/1-: � Dale Vernon Breaker � Ma.le, ,� ;Ap�il, 5;' M�UO2 4. CITV AND STATE OF BIRTH lilrrot ln USA, neme co�nbyl Sa. AGE • Lest Birthday UNDER 7 YEAR UNDEH� i Y'� '` �&`DATE�OF BIRTN �. /Mm'tla Day. Yearl (Yrs.l 5b. MOS. � DAYS Sc. HOURS � M�NS � � Arapahoe, Nebraska 77 ' "` Ju�e 16, 1'924 , 7 SOCUU, $ECUHTIY NUMBER 8a. PL4CE OF DEATH . f" .~~ �'. _ HOSPITAL: � InpadBM r OTHER� � �NurS��HOm¢� � 508-18-9552 � Bb. FACILITV-Name /OrrolnaD'fu!lon,givesdeetarWnumber) � EROuq�atiem � Res�dence St. Francis Medical Center � D0A � 8c. C1TV TOWN OR LOCATION OF OEATH BA. INSIDE CITY LIMITS 8e. COUNTV OF DEATH Grand Isl Y� � � ❑ Ha 9a RESIDENCE - STATE 9b. CWNTY � 9c. CITV. TOWN OR LOCATION � 9E. STREET AND NUMBER /!neludirtgZrp Code� 9e. INSIDE CITY UMRS Ne braska _ � Ha ll _ Grand Isl and 1711 Bridl.e Lane 68803 �� N� ❑ -_- - -- --- - - 10. � RACE • �e.g, WhAB. Black Amerxan Intlian. 1 t. ANCESTRY Ie g.. ltalian. MexicaR (3erman etcl 12. � MARFtIED ❑ WIDOWED 73. NAME OF SPOUSE nl wAe. give meiden nemeJ ek.11Soeclh/) �SPecdY) NEVER DIVORCEO Whit A merican ❑ Margaret C. Wieczorek - - -- taa USUALOCCUPATION lQrvekirMOlwO�kdrnredwlrtgma5t 14b. KINOOFBUSINESSINDUSTRV 15 EDUCATION �SpetiyoNylugFreS[gradeeanpletetl� a ww�c �ae. even il.ernea� . Carpenter Railroa �egth°`Gra�e-'�' �°"�B ��-aas•� 18. FATHER • NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIOEN SURNAME F red W B r ea ker Nellie I. Retherford - --- - - - i& WAS DECEASED EVFA M U.S.ARMED FORCES7 19a INFORMANT•NAME Ives. rro. w untc� lif yes gne war aM Gates of sarvices�_ No ----- Ma_rgaret C. Breaker 19E. INFORMANT - MAILING ACH]RE55 fSTREEf OR R.F.D. NO.. CIN OA TOWN. STATE. ZIP) � 1711 B ri d le Lane, Grand Island, Nebraska 68803 20. E L R• SIGN URE 8 ENSE NO. � 21a METHOD OF DISPOSITION � 21b. DATE 21a CEMETERY OR CREMA70AY � NAME _(�' , G�� d �� 9 � �� ❑ ae��a� A r. 9 2002 Westlawn Memorial Park 22a. FUNERAL H(�- NAME �� - 21tl. CEMETEAV OR CREMATORY LOCATION CITY OR TOWN STATE Livingston-Sondermann F.H. ��`�'"�°" � Gra Island Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR RF.D. NO.. GTY OR TOWN. STATE, DP� -- . 601 N. We R oa d , Grand Island, Nebraska 68803-4050 23. � IMMEDIATE CAUSE �ENTER ONLY ONE CAUSE PER LINE FOR lal. (b�. AND �c�� I Irrterval helween onset and tleam pART I- � � � ��(dl �� r �V �� {1�1/_lil�/ Si' C// i"G"�/°� I� � i7 �{�1 �+l K.S - -� - �. Interval Detween onset arW tleatn DUE T0. OR AS A CONSE�NCE OF�. � I � ro� fI hG'r� n�On !J - - - ��°VFY� � �!'a v. s - DWE TA. OR AS A CONSFOUENpE OF' . � � . I Interval beRvoen onset d deafi / I I �C� � OTHER SIGNIFICANT CONDITIONS • CMd'NOns CaitribuGng to the dealh but �wl reiatetl � PART III if PEMALE. WAS THERE A 24. AUTOPSV 25. WAS CASE REFERRED TO MEDICAL PART ' / PREGNANCV IN THE PAST 3 MONTHS? EXAMINER OR CORONER� 'I }�P�'IG_� I - l/15G'��lG/G ° �C1� : ��'1'IC�HT/16/ IA9es to ves ❑ No ❑ v�s ❑ No �, ' ve5 � rvo �_ 26a. �b. DATE I RY /Ma. Day. Yr.) 26c. HOUH OF INJURV 26d. DESCRIBE HOW INJURY OCCURRED � Acc�tl@M � UntleterminEtl M � SmCide � Pentlmg � 28e. INJURY AT WORK 261. P�Ce E OF I�NdURY %A( ho larm. StreSt leetory 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE Mrildi Spe � Hpmicitle InveSdgalWn ygs O No ❑ ' '� � ✓ OY/ � � uZ 27b. DATE SIGNED /MO.. 0ay. Yr./ 27c. TIME OF DEATH a o � � 12. 30 A.1'L. � � M 270 To the best o my knowledge. th ocCUrr¢E et t�e 5m8. tlate and p1ac8 aM due ro the � J � ( �auselsl state0. 'A y � (SignatureandTide�► - -�'✓��i / �'V 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 30a HAS ORGAN OR TISSUE DO � � VES � NO � UNKNOWN �C � YES --_ 3L � NAME AND ADDRESS OF CENTIFIER �PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATiORNEVI /T� g�¢ M $`° K 28c. PRONOUNCED DEAD lMa.. Dey. Yc) 28d. PRONOUNCED DEAD (Hpun �� a � z � M � � ° o� 28B. On U1B b3313 0� 0x3minal�on aM � Of v1YeSbgatiOn, in my OD�� tleath oCGUrted e� u s s the ome, tlate and dace ana aue ro the causelsl stated. BEENCONSIDERED� 3�0 WASCONSENTGRAN7ED7 IYI NO l � VES y .�,., NO 328. REGISTRAR // � � /�� • - 32ti. OATE FlIEB I 1 .0�! J � p9