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<br />TYPE OR PRINT IN
<br />PERMANENT
<br />SEE INSTRUCTION
<br />MANUAL
<br />Place
<br />NSC
<br />Work
<br />UC.
<br />Reject
<br />117 A
<br />00
<br />Y'r
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<br />Part 11
<br />TMV
<br />Census Tract No.
<br />BVS -2 020-M-008 12-82
<br />STATE OF NEBk3tr.ic [DEPARTMENT OF HEALTH
<br />3UREAU OF VITAL STATISTICS
<br />C :RTIFICATE OF DEATH
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />1. Earle Ray Spiehs
<br />SEX
<br />1 Male
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />1 June 11, 1986
<br />RACE- (e.g., Whirr, Block, Amor/con
<br />Indian, sk.) (Spscity)
<br />4. "White
<br />ORIGIN /DESCENT(s.9., Italian.M.sicon,
<br />Gorman, sk.) (Sp.. y)
<br />s . American
<br />AGE -Low CH!dey
<br />(Y.4)
<br />60. 62
<br />UNDER 1 YEAR I UNDER 1 DAY [ DATE OF BIRTH (Me,, Day, Yr.)
<br />MOS. . DA.YS HOURS MINS.
<br />A t, 1 6 ,, : ,Feb. ,. 18, 1924
<br />Z'
<br />W-
<br />UJ
<br />KJ
<br />CITY AND STATE OF BIRTH (H not in U.S.A.,
<br />country)
<br />B. Doniphan, Nebraska
<br />CITIZEN OF WHAT COUNTRY
<br />9, U.S.A.
<br />MARRIED, NEVER MAitR1ED, NAME OF SPOUSE (if rife, give maiden name)
<br />WIDOWED, DIVORCED (Sp.ci!y)
<br />1 Married 1/ ,Thelma Farris
<br />SOCIAL SECURITY NUMBER
<br />12. 506 -20 -4269
<br />USUAL OCCUPATION
<br />of working tile. even
<br />13a. Construction
<br />(Give kind of work
<br />if retired)
<br />/Foreman
<br />dons during most
<br />KIND OF BUSINESS OR INDUSTRY
<br />Building
<br />13b. Construction
<br />COUNTY OF DEATH
<br />14a. Hall
<br />`"`-
<br />,,
<br />CITY, TOWN OR LP:ATION OF DEATH
<br />14b. Grand Island
<br />INSIDE CITY LIMITS
<br />(Spsc Yes or No)
<br />14c. Yes
<br />HOSPITAL OR OTHER INSTITUTION - Nome (If rot In either, 1 11 HOS?. OR INST. 1.4..,. DOA.
<br />oho :frost and number O.tpati.nt /t0er. Rya., Inpan.nt (Sp..Uy)
<br />144 Grand Memorial Hosp.1 Emer. Room
<br />RESIDENCE - STATE
<br />1sa.Nebraska
<br />COUNTY
<br />1sb. Hall
<br />cm, TOWN OR LOCATION
<br />Ise Grand Island
<br />STREET AND NUMBER
<br />1Sd. 4055 Airport Rd.
<br />INSIDE CITY LIMITS
<br />(Specif Yst or No)
<br />1N, ' Y • es
<br />le:
<br />FATHER -NAME FIR
<br />!6 Charles
<br />M1004. LAST
<br />Henry Spiehs
<br />MOTHER - MAIDEN NAME FIR T MIDbLE LAST
<br />1 Amanda - -- Schwieger
<br />A 7;
<br />•
<br />F- s
<br />C,
<br />PM
<br />(7;.
<br />WAS DECEASED
<br />(T.s, no, or .nk)
<br />18 . No
<br />EVER IN U.S. ARMED FORCES?
<br />Of yew, g... .or and dots of wince)
<br />INFORMANT -RELATIONSHIP-MAILING ADDRESS (STREET OR R.F.O. PO., CITY OR TOWN, STATE, ZIP)
<br />n
<br />1 9Thelma Spiehs- Wife -4055 Air ort Rd. -Grand Island, N
<br />BURIAL, Cremation, Rsmoval
<br />200. Burial
<br />DATE
<br />June 14 , 1986
<br />20b.
<br />CEMETERY OR CREMATORY -NAME
<br />20c. Grand Island Cemetery
<br />LOCATION CITY OR TOWN STATE
<br />god. Grand Island, Nebraska
<br />EMBALME c • GNATURE fLICENSE 4o.'Q.4GJ
<br />/
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, LP)
<br />22 Apfel- Butler - Geddes 1123 W. 2nd, -Grand Island, NE. 688(
<br />H
<br />y Tas/eldwaJ w °1
<br />0 E OF OE+tTM? ., C
<br />230. '-
<br />T. I• Cswls.sd 6y
<br />CORONER'S PHYSICIAN,
<br />sr COUNTY ATTORNEY
<br />only
<br />DATE SIGNED (Mo. Dot, Yr.)
<br />240.
<br />HOUR OF DEATH
<br />24b. M
<br />DATE SIGNED (Mo., Day, Yr.)
<br />� 7 !/
<br />23b. 6 v 2 1 - 7 IGJ
<br />HOUR OF DEATH 3
<br />� 7
<br />23c. / L M
<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
<br />244.
<br />PRONOUNCED DEAD (Hour)
<br />tad. M
<br />To the bad s .4 no kno.).dg.. d turn at M lino do and pi.c .4 d.. . dm
<br />%
<br />234. Mynot.ro and TRW , A �
<br />, in my opinion Meath occurred
<br />On M. bon. of ..an.inotian . .d/or in..fgonen a a
<br />Me
<br />e lime, dote end place and duo to Me cou..(s) *toted.
<br />24e. (Signets) and Tid.)
<br />=.
<br />.kits
<br />42.:
<br />^�
<br />'E R
<br />", .
<br />NAME AND ADDRESS OF CERT (PH75 , C ()NEWS PHYSICIAN OR COUNTY ATTORNEY) ( Typo or Print)
<br />23. C. D. McGrath M.D. 729 N. Custer, Grand Island, NE. 68801
<br />REGISTRAR
<br />264. (Sign.t.n.) '
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />26b
<br />27. IMMEDIATE CAUSE (ENTER ONLY •NE CAUSE PER ,.4412TOR (a), (b), AND (c)) .y : Interval between on.erand d.&4.
<br />PART c %._ _
<br />DUE TO, OR AS A CON E• ENC E OF; , if `� ins.r.ol her. e.n *mad and death
<br />(b) �.A/ �. .Ad_4 J L u �- V ; i 1
<br />DUE TO, OR AS A CO SEQUENCE OF: In b.s.e.n armor rind death
<br />(e) 1
<br />PART OTHER SIGNIFICANT CONDITIONS- Condition. conrrib.ang p deoM but nM related
<br />11�-�
<br />...vv.- ~ -
<br />PART tlI. IF FEMME. WAS THERE
<br />PREGNANCY IN THE PAST hASi 3 MONTHS?
<br />ref (] tvo t..J
<br />(Sp .fp
<br />28 (Spat,, r err No)
<br />28.
<br />WAS CASE REFERRED MEDICAL
<br />EXAMINER OR CORONER
<br />E!
<br />( Sp.e.fy Tor or No)
<br />29.
<br />ACCIDENT, SUICIDE, VOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION. (Specify/
<br />30a. '�
<br />DATE OF INJURY (Me., Day, Yr.) I HOUR OF INJURY
<br />�..- --
<br />306. 1 t30e. M
<br />DESCR)R£ HOW INJURY OCCURRED
<br />l 30d.
<br />INJURY AT WORK
<br />(Sp.cify Y.s or Net
<br />PLACE Of INJURY- At home. form, sb..s. 4*dory.
<br />attic. building, Mc. (Specify/
<br />LOCATION STREET OR LE 0. No. CITY OR TOWN STATE
<br />f_•
<br />30o.
<br />302.
<br />�
<br />30r3 .
<br />w
<br />-J
<br />TYPE OR PRINT IN
<br />PERMANENT
<br />SEE INSTRUCTION
<br />MANUAL
<br />Place
<br />NSC
<br />Work
<br />UC.
<br />Reject
<br />117 A
<br />00
<br />Y'r
<br />tl
<br />O
<br />v�
<br />}
<br />z" c
<br />0
<br />ce
<br />0
<br />Part 11
<br />TMV
<br />Census Tract No.
<br />BVS -2 020-M-008 12-82
<br />STATE OF NEBk3tr.ic [DEPARTMENT OF HEALTH
<br />3UREAU OF VITAL STATISTICS
<br />C :RTIFICATE OF DEATH
<br />
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