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1. DECEDENT - NAME FIRST MIDDLE LAST
<br />Cecil Stanely Owen
<br />2. SEX I
<br />Male
<br />3. DATE OF DEATH (Month, Day, Yeu)
<br />March 15, 1993
<br />WRTH not m U.S.A., name country)
<br />5a. AOE - Laat Birthday
<br />(Yra.)
<br />71
<br />HOSPITAL: 0 Inpatiem
<br />UNDER 1 YFAR
<br />UNDFR 1 DAY
<br />6. DATE OF BIRTH (Month, Dey, Year)
<br />March 23, 1921
<br />4 CITY AND STATE OF /N
<br />.. Memphis, Nebraska
<br />- 7. SOCIAL SECURITY NUMBER
<br />8e. PLACE OF DE
<br />/�
<br />5b. MOS. 1 DAYS
<br />y �
<br />p ERiOutpaEint
<br />Sc. HOURSI MINS.
<br />t
<br />0 DOA
<br />506-18-6827
<br />O O 0 Residence O Older
<br />OTHER: Nursing Home /Specify)
<br />j 95. FACILITY - Name IN not institution give street and number(
<br />• St. Francis Medical Center.
<br />8c. CRY, TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />89. INSIDE CITY LIMITS
<br />(Speci) Yes or No)
<br />Yes
<br />8e. COUNTY OF DEATH
<br />Hall
<br />- 9a RESIDENCE - STATE
<br />Nebraska
<br />95. COUNTY
<br />Hall
<br />9c. CRY, TOWN OR LOCATION
<br />Grand Island
<br />9d. STREET AND NUMBER (Includng Zip Code)
<br />621 S. Eddy 68801
<br />9e. INSIDE CITY LIMITS
<br />(Specify Yes a No)
<br />Yes
<br />t0. RACE - (e. 4vhAe, Black American Indian,
<br />eel (See d/0
<br />White
<br />11. ANCESTRY (0.9.,Kakan, Mexican, German, etc.)
<br />(Specify)
<br />American Q
<br />12. MARRIED,NEVER MARRIED,
<br />WIDOWED, DIVORCED /Specify)
<br />Married
<br />13. NAME OF SPOUSE (N wife, give maiden name)
<br />Vivian Thompson
<br />t4a USUAL OCCUPATION (Give kind of owe done during most
<br />of working iiie, even d nh'red) -
<br />'
<br />_ Insurance Agent s53
<br />14b. KIND OF BUSINESS INDUSTRY -
<br />Insurance 1
<br />surance
<br />15 EDUCATION IRrerity onN 5155081 Dade ton14etedl
<br />Elementary of Secondary 10 -121 I College (1.4 ors.,
<br />12th Grade
<br />-18. FATHER - NAME FIRST MIDDLE UST
<br />• Lester NMN Owen
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Calista NMN Connor
<br />18. WAS DECEASED
<br />(Yes, no. a unk.l
<br />Yes
<br />EVER IN U.S. ARMED FORCES?
<br />(8 yes, give war and dates of services)
<br />1- 28- 42/11 -15 -45
<br />19. INFORMANT - NAME • MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, 2181
<br />Vivian Owen, 621 S. Edd , Grand Island, Ne.68801
<br />20a. BURIAL, Cremation,Ramoval,
<br />Donation
<br />Burial
<br />205. OATS
<br />Mar. 18,1993
<br />20c. CEMETERY OR CREMATORY - NAME
<br />Westlawn Memorial Park
<br />20d. LOCATION CITY OR TOWN STATE
<br />Grand Island, Nebraska
<br />21. BALMER - SIGNATURE & LICENSE NO.
<br />R 43
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, 218 8 8 0 1
<br />-ivingston- Sondermann 505 W. Koenig, Grand Island, Ne.
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes ❑ No D
<br />24. AUTOPSY } I
<br />i
<br />• II 1V' 1
<br />25. WAS CASE REFERRED T��) MEDICAL
<br />EXAMfyER OR C o)
<br />'1(,. .:5= yYes or CO
<br />26a. ACCIDENT. SUICIDE, HOMICIDE. UNDET.,
<br />OR PENDING INVESTIGATION (Specify)
<br />265. DATE OF INJURY (Mo.,Day, Yr.)
<br />26c. HOUR OF INJURY
<br />M
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />26e. INJURY AT WORK
<br />(Specify Yes or No)
<br />26f. PLACE OF INJURY - At home, farm, street, factory,
<br />office building, etc. (Specify)
<br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />27a. DATE OF DEATH Mo., Day, Yr.)
<br />IS
<br />i k
<br />rg
<br />o
<br />8
<br />28a. DATE SIGNED (Mo., Day, Yr)
<br />285. TIME OF DEATH
<br />lii
<br />8
<br />27b. DATE SIGNED (Mo., Day, Yr.)
<br />A ,- 3 1�
<br />27c. TIME OF DEATH
<br />A, Z A �.
<br />28c. PRONOUNCED DEAD (Mo., Day, Yr)
<br />280. PRONOUNCED DEAD (Hour
<br />M
<br />270. To the beat of my k Gfcyn to - place and • the
<br />eayeela) stated
<br />28e. On the basis of examination and;or investigation. in. my opinion death occurred at
<br />10 the Urns, date and glade and due to the causes) stated.
<br />(Signature and Titie)19
<br />X
<br />(Signaaaa and Tate
<br />- 29e. DID TOBACCO USE CONTRI HE DEAT
<br />0 YES ONO UNKNOWN
<br />- , . HAS ORGAN OR TISSUE DONATION BEEN CON FRED?
<br />..›r"' 0 YES NO
<br />300 WAS CONSENT GRANTED?
<br />0 YES t0 P I
<br />31. NAME AND ADDRESS • C TIF R IPHYSICIN, C NER'S PHY NOR COUNTY ATTORNEY) (7 0 Print) �„ i f
<br />h :
<br />32a. REGISTRAR '' I
<br />'
<br />32b DATE FILED BY REGISTRAR (Mc., Day. Yr.)
<br />MAR 2 2 1993
<br />23. IMMEDIATE CAUSE
<br />PART
<br />I
<br />181
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />141
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAR 23 1993
<br />LINCOLN, NEBRASKA
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />231307565
<br />(ENTER ONLY ONE CA SE PER LINE FOR ( (5), AND (cO
<br />STANLEY S. COOPER, DIRECTOR
<br />BUREAU OF VITAL STATISTICS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />Interval between onset and death
<br />Interval between onset and death
<br />
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