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t. DECEDENT - NAME FIRST tt12Ol.1 LAST <br />ALBERT ELDON PANEC <br />1 SEX <br />MALE <br />3 °M CA OEATH ~I. Ole Wed <br />MARCH 1 EIS <br />4 CITY APOSTATE OF BIRTH Neon 05.4. nom aaNrYyt <br />PAWNEE CITY, NEBRASKA <br />SL ' - LAO <br />rm1 66 <br />UNDER I YEAR <br />• I DAY <br />6 DACE Of Day. YAW <br />JULY 5, 1934 <br />Mos DAYS <br />5c. HOURS MS <br />7. SOCIAL SECURRY NUMBER <br />505 -40- 1700 <br />St PLACE OF DEATH <br />Hamm <br />EA "igLCU OTHER. ❑ aiarsA°Na,• <br />0 mow.. <br />❑ 00A <br />■ <br />❑ <br />RladSaCe - <br />°" <br />- 80 FACILITY - Nome p a * , <br />VA MEDICAL CENTER <br />28c PRONOUNCED DEAD No Day F, • <br />- 6c CITI' TOWN OR LOCATION OF DEATH <br />I GRAND ISLAND, NEBRASKA <br />Ile ee E CITY LIFTS <br />Yeti Ei Na ❑ <br />is COUNTY OF DEATH <br />S. RESIDENCE - STATE <br />NEBRASKA <br />SD COUNTY <br />HALL <br />S. CITY. TOWN OR LOCATION <br />GRAND ISLAND <br />!Q STREET ANO NUAbER pr+d'6y1bCadl <br />2523 V CHARLES 68803 <br />ie weitsectertfrIS <br />N- Q w 0 <br />M <br />70 RACE • (e.g, WI . Blau. Manua NRAn. 11. ANCESTRY lag_ IOW •Nee 0.1111111. MG <br />g+<' Soft -ea WHITE 1 (so.F� CZECH <br />12 MARRIED O <br />a °I '`' <br />NAME AT b <br />oS N OF SPOUSE a.r SeRTNResnnlW <br />MILDRED SHIM <br />tee. USUAL OCCUPATION /Oat Redd work done Nov moos/ <br />oIwheg Nee non /7eYT10J <br />JOURNALISM <br />116 AND OF WNW* INDUSTRY <br />1 NEWSMEDIA <br />15 EDUCATION ISPSCIy ON/ ANNA INN a:WNW <br />Elemesay W Seem:In 10 -121 COW II1d5 1 <br />12 5+1 <br />PAR' OTHER, S1GNIRCANT CONDITIONS - CoNbeoes csI* 61Mp b Ns MO but nil WNW <br />I' REPAIR OF LEFT VENTRICULAR ANEURISM <br />PART N if FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS' <br />(Ages 1.0 -54l Yes No 0 <br />24 AUTOPSY <br />yes [ lea E <br />MEO <br />25 WAS CASE 1 MEDICAL <br />EXAMINER OR CORONER' <br />Y., C1 Na la <br />26a i 26o DATE OF INJURY lab. Day. 1 <br />r 1. AccIenI 0 U ealergvnect L...._ <br />26c HOUR OF INJURY <br />M 1 <br />_0 <br />T2ed DESCRIBE NOW INJURY OCCURRED <br />M. PA l <br />NAY Swcos 0 PeM i 26e AJRY AT WOWS 1 2W <br />D ..... JN MvesH i Yas ❑ Na 1111 <br />PLA OF N f9 SIML+N lm. M Y , - U . Ism sweet facary - I <br />aI MC 1 % MOR <br />264. LOCATION STREET GR R L O NO Cr, v OR TOWN STATE <br />i 27a DATE OF DEATH 144, Day ••! f <br />200 <br />3 i � MARCH 15, � <br />28s DATE SIGNED Mc ON n) <br />266 THE OF DEATH <br />r <br />�t 1 270 DATE D AU May ay i 27e <br />07.) dtot <br />TARE OF DEATH <br />� l 600 AM <br />d <br />28c PRONOUNCED DEAD No Day F, • <br />280. PRONOUNCED DEAD dbr <br />L w <br />0 o e e or anovaa04e /, <br />uJ <br />• ! <br />7 T <br />( , S 'we and TdN 5 <br />• <br />• at <br />J <br />J <br />i <br />ems dal W6 Our a OM , . E <br />1 J 0O <br />11 On ale bin* 01 saronaM ana at lay maw. *NW occuma0 al <br />28 a a m rcn n av <br />bk the MN. 0116 and ae and d4 N Ile tamps+ MOM <br />ISq+rut and Thiel 0 <br />_ _ <br />, 29 DID TOBACCO USE CONTROUTE TO THE • ! <br />I YES � ( NO ■ ;pY(►gWN <br />30 HAS ORGAN OR TISSUE DONATION BEEN CONSOERED' <br />YES E NO I <br />306 WAS CONSENT GRANTED' <br />O YES ® NO <br />16 FATHER - NAIVE <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT FAUN Avg <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIq[& L 'RECciF V .Ott <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VIT, L <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS, , c j L . , <br />DATE OF ISSUANCE <br />SEP 2 <br />201 <br />3 S T, N.LE '4 < QOJ3ER <br />201308040 DE • TMFNT OF HEA TIj- A(ND, <br />H �, <br />NEBRASKA JM T $E VICES , ' <br />STATE OFNEREAS[MOB►AR71�flOSMIA IN I <br />/ANRVIC[IS FIrANCE <br />'MAL SrmssES 9 <br />CBR11FICATE OF DF.A <br />LINCOLN, <br />FWST PADDLE LAST 17 SOOTHER FIRST <br />ALBERT (MIN) PANEC 1 THELMA IRENE <br />18. WAS DECEASED EVER IN US. AWED FORCES? T 1St rlOR1118l. NAME <br />(Yes. no. or alk 1 IM yes 9'•e ow and dales of sene•ty <br />YES (VIETNAM ERA 4/5/55 - 4/4/61 LpANEC. MTLDRFn <br />190 INFORMANT MAILING ADDRESS 'STREET OR R O NO. CRTs OR TONIN. STATE. 21P1 <br />2523 W CHARLES ST., GRAND ISLAND, NEBR. 68803 <br />MEP ZP4 /17 / <br />ALL FAITHS FUNERAL HOME <br />226 FUNERAL HOME ADDRESS ISTREET OR R.F.O. NO CITY OR TORN. STATE DPI <br />[id &era ❑ Removal <br />ALL FAITHS FUNERAL HOME, 2929 S. LOCUST ST. GRAND ISLAND. NEB. 68R01 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ia,. eJ. AND Icil <br />- PART - <br />' , CARDIAC ARRHYTHMIA <br />DUE TO. OR AS A CONSEOVENCE OF <br />1 ,, MYOCARDIAL INFARCTION <br />DUE TO. OR AS A CONSEQUENCE OF <br />CORONARY ARTERY DISEASE <br />AR .H 19 21301 n TBaIc r v <br />214 CEMETERY OR CRE MATORY LOCATION CITY OR T� I <br />0...0m., DUBOIS, NEB. <br />Tyne or J3nry <br />A.00LE <br />-1 SEBRING <br />21a METHOD OF DISPOEIT+O14 216. DATE T Ztc. CEMETERY OR CREMATORY - NAME <br />larval Wasson cram are avow <br />MINUTES <br />Meavt 6alseP aisle and Main <br />MI3UTES <br />Meava oerwn 0np1 a a main <br />YEARS <br />STATE <br />31 NAME AND ADDRESS OF CERTIFIEA +PHYSICIAN (%)BONER S PHYSICIAN OR COUNTY ATTORNEY, - <br />DRINCIC, VISESLA VA MEDICAL CENTER 2201 N BROADWELL. GRAND TSLAND. NFRR_ 6RRt13 <br />32a REGISTRAR O� if j 320 DA FILED BY REGISTRAR .ab O w , <br />I <br />MAR 2 1 2001 <br />