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- D- CEDENT -NAME FIRST M1DULE LAS) <br />Franklin John Brower, Jr. <br />2 SEX 3 DATE OF DEATH (Mono Da , > ea <br />Male' April 29, 2001 <br />4 CITY AND STATE OF BIRTH Ono( in USA.. name country) <br />Sheldon, Iowa <br />5a. AGE - Last Birthday <br />"f51 47 <br />UNDER 7 YEAR <br />UNDER 1 DAY <br />6 DATE OF BIRTH /Month. Day Year) <br />February 11, 1954 <br />b MOS DAYS <br />5c HOURS MIN, <br />7 SOCIAL SECURTIY NUMBER <br />483-58-2684 <br />83 . PLACE OF DEATH <br />HOSPITAL ❑ Tpatienl OTHER II <br />ER Outpatient ❑ <br />❑ DOA ❑ <br />Nursing Home <br />Residence <br />Other /Spen4; <br />Bb FACILITY - Name fit not 1081i(unon. give street and number) <br />St. Francis Medical Center <br />8, , ^111 TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d. INSIDE CITY LIMITS <br />Yes No C <br />9P. COUNTY OF DEATH <br />Hall <br />9a RESIDENCE - STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />98. STREET AND NUMBER /Including Zip Code) <br />4129 Cannon Road 68803 <br />9e. INSIDE CITY LIMITS <br />Yes No ❑ <br />1 0 PACE - le -g.. White. Black American Indian <br />etc I ISoec4f <br />White <br />11 ANCESTRY le .g Italian. Mexican. German. elcl <br />ISpec■y) <br />Dutch <br />12. x MARRIED ❑ WIDOWED <br />NEVER DIVORCED <br />❑ MARRIED ❑ <br />13 NAME OF SPOUSE d) wile give ma den name) <br />Joni Phillips <br />taa USUAL OCCUPATION (00v0 kind of work done during most <br />of working We even It refired/ <br />Claims Manager <br />1 45 KIND OF BUSINESS INDUSTRY 1 <br />State Farm Insurance <br />15 EDUCATION ISpecily only highest grade completed) <br />Elementary or Secondary (0 -12) College 11 .4 or 5.1 <br />5 Years <br />16 FATHER - NAME FIRST MIDDLE LAST <br />Franklin John Brower, Sr. <br />1 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Geraldine Van Roekel <br />16 NA DECEASED <br />Yes. n, or unk - ) <br />No <br />EVER IN 85 ARMED FORCES, <br />1 11 yes a ve war and dales 01 services) <br />198 INFORMANT NAME <br />Joni Brower <br />DATE OF ISSUANCE <br />LINCOLN, NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />196 INFORMANT <br />MAY - 4 2001 <br />4129 Cannon <br />MAILING ADDRESS (STREET OR RF 0. NO CITY OR TOWN. STATE. ZIPI <br />/EMBALMER - SIGNATURE 8 LICENSE NO <br />//4 3 <br />22a FUNERAL HOME - NAME <br />Livingston - Sondermann F.H. <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />23. IMMEDIATE CAUSE <br />A/PART <br />aI Acute M i <br />DUE TO. OR AS A CONSEOUENC OF <br />Ibl <br />268 <br />Acc810,71 Undetermined <br />Sulclde Pending <br />Homicide Investigation <br />L- <br />274. DATE OE DEATH iMO Day. 27 ) <br />32a REGISTRAR <br />DUE TO OR AS A CONSEQUENCE OF <br />27b. DATE SIGNED fMO.. Day Yr./ <br />cause', slated. <br />(Signature and TNe) ► <br />- 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH, <br />T ❑ VES ❑ NO Vf UNKNOWN <br />201307013 6T ANLEY S. COOPER <br />ASSISTANT STATE REGISTRAR <br />HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />Road, Grand Island, Nebraska 68803 <br />rdi.1 nf.r <br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related <br />PART <br />II <br />26e INJURY AT WORK <br />Yes ❑ No ❑ <br />21a METHOD OF DISPOSITION 21 b. DATE <br />© Burial ❑ Removal <br />❑❑ Cremation ❑ Donator <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />(ENTER ONLY ONE CAUSE PER LINE FOR 01. 15). AND )c5 <br />• , <br />PART III IF FEMALE. WAS THERE A 24 AUTOPSY <br />PREGNANCY IN THE PAST 3 MONTHS, i <br />( Ages 10-541 Yes No ❑ I Yes <br />261, DATE OF INJURY (Mo. Day. Yr.) 26c HOUR OF INJURY ; 2Ed. DESCRIBE HOW INJURY OCCURRED <br />M <br />261 PLACE OF INJURY - At home. 18,6 street factory <br />office bolding etc. (Specify) <br />27c. TIME OF DEATH <br />27d To the best of my knowledge death occurred at the time date and place and due to the <br />X Jerom F, ,Tanulewi cz - Ha1 1 Qoun <br />M <br />308 HAS ORGAN OR TISSUE DONATION BEEN '' <br />EEN CONSIDERED <br />B <br />❑ YES VI NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER S PHYSICIAN OR COUNTY ATTORNEY Tvoe or Punt) <br />May 3, 2001 j Eastlawn Cemetery <br />215 CEMETERY OR CREMATORY LOCATION CITY OR TOWN <br />Sheldon, Iowa <br />26q LOCATION <br />28c PRONOUNCED DEAD ;Mo.. Day. Yr <br />L l <br />28ee,„On the basis of e .con antl o •tigallon, in my opinion dealn occurred at <br />the ome. date an. - and hue . cause's t l.ted <br />30.5 � S CON ENT, .ANTED <br />IS nature and Tltlel <br />28d. PRONOUNCED DEAD (Hour) <br />284 DATE SIGNED /MO. Day Y' I <br />01 04698 <br />216 CEMETERY OR CREMATORY - NAME <br />STREET OR RF.D. NO <br />STATE <br />I Interval between onset and death <br />I <br />unknown <br />Interval between onset and death <br />Interval between onset and death <br />25. WAS CASE REFERRED TO MEDICAL <br />3 EXAMINER OR CORONER <br />Yes X No <br />CITY OR TOWN <br />STATE <br />28b TIME OF DEATH <br />approx <br />1 1 7 7 20 087E F r and yA � M �a '�U13E 6880 <br />