|
8c CITY TOWN OR LOCATION OF DEATH Tad INSIDE CITY LIMITS
<br />Grand Island Nebraska 1 Yes al -
<br />•
<br />8e COUNTY OF DEATH
<br />hall
<br />98. RESIDENCE. STATE 196 COUNTY
<br />Nebraska 1 Merrick
<br />9c CITY TOWN OR LOCATION
<br />St. Libory
<br />90 STREET AND NUMBER ,mckdeMZOCede/
<br />R.R. 1 68872
<br />9e 81582E CITY TWOS
<br />Y« ❑ f10 pi
<br />10. RACE - leg. WI e. Black American Indian .
<br />NC) (Specdyl
<br />White
<br />I 1 i. ANCESTRY leg Italian. Mexican. Ginner. Ski
<br />ISOecd Z yl
<br />Norwegian /German
<br />WIDOWED
<br />' 12 n � MARRED 1:11
<br />(]
<br />0 NEVER NEVER0 El DIVORCED
<br />13 NAME OF SPOUSE /a r wormed. *
<br />4 'W
<br />Norma Shipman
<br />14a. USUAL OCCUPATION (Gee kw1ohm* done dtkg most
<br />of wane lie even e/eere*
<br />-
<br />Farming , ..‘, -- c:. -, , ..‘, -- c:. -,
<br />140 KIND OF BUSINESS INDUSTRY
<br />�\
<br />�
<br />Agriculture
<br />15 EDUCATION (Speedy Only hgMA grade cons W."
<br />Elerne.eMY 12) College 11.4 or S.1
<br />�y t0
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />Onen Simonson
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNIWE
<br />Hedwig Wagner
<br />18. WAS DECEASED EVER IN U S. ARMED FORCES?
<br />(Yes. no. or u k.) I II yes. give ear and dales of services)
<br />Yes W.W. II 1952 -1954
<br />19a INFORMANT - NAME
<br />Norma Simonson
<br />190. INFORMANT MAILING ADDRESS (STREET OR R.F D. NO. CITY OR TOWN. STATE. ZIP)
<br />R 1 . Libory, Nebraska 68872
<br />20. E .-,- a - • SIGNAT RE 8 LICE .ENO.
<br />7-
<br />21a METHOD OF DISPOSITION
<br />X Bunal ❑ REWOYal
<br />❑`fe ❑°°
<br />210 GATE
<br />Nov. 25,1994-Norwegian
<br />21c CEMETERY OR CREMATORY NAME
<br />Cemetery
<br />A
<br />-" ' • AME a
<br />Greenway - Palmer Funeral
<br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Worms, Nebraska
<br />220. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP)
<br />Box 84 Palmer, Nebraska 68638
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contnbUeg to We death Out not regaled
<br />11
<br />PART el IF FEMALE WAS THERE A f 24 AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />r �
<br />(Ages 10.54( Yes ❑ No ❑ f Yes ❑ No V '
<br />25 WAS CAST REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'?
<br />(� K
<br />Yes L I No I
<br />26a
<br />UrnIelene0
<br />El Accident . rnx
<br />❑ Swede • Pending
<br />j �
<br />L_J Irprreeudt MvestgaIs,n
<br />260 DATE OF INJURY (Mu. Day. Yr)
<br />26c HOUR OF INJURY
<br />M
<br />264. DESCRIBE HOW INJURY OCCURRED i
<br />26e INJURY AT WORK
<br />YeS ❑ Na ❑
<br />261 Pu ll E OF INJ - M cOy! home. farm street factory
<br />dec Idn SPe
<br />269 LOCATION STREET OR RE D NO CITY OR TOWN STATE
<br />ANO
<br />NviOtSANd 6.044. I
<br />27a DATE OF DEATH lMo Day Trl
<br />i1 — zz - 9y
<br />To be Compleleb b.
<br />CORONERS PRYSCIAN
<br />COUNTY ATTORNEY
<br />ONLY
<br />286 DATE SIGNED ;Ate Day Y
<br />2813 TIME OF DEATH
<br />M
<br />270 DATE SIGNED Wo Day Y r)
<br />f2 L - Ra-/
<br />27c TIME OF DEATH
<br />/
<br />�rY M
<br />28c PRONOUNCED DEAD !Me Day. Y, l
<br />28d. PRONOUNCED DEAD /ho
<br />/Norm
<br />M
<br />270 To me pew d my krgwW ... c unee at m nin
<br />e e, da - pt. e a .. to the
<br />tarsals) Stated. ♦ -
<br />Bared Tee) IP • -
<br />28e On M d aa
<br />e Oasts erne ton and or inve50941mm m my opener) deM6 occurred at
<br />' me time. dale and place and due tote camels) Slated
<br />r
<br />!Sa and Tore) la
<br />29 DID TOBACCO USE CONT •, : E TO HE DEATH?
<br />❑ YES ❑ NO UNKNOWN
<br />30a a • AN OP TISSUE DONATION BEEN CONSIDERED?
<br />to YES II NO
<br />36 WAS CONSENT GRANTED?
<br />YES ❑ NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER 5 PHYSICIAN OR COUNTY ATTORNEY) l Type P Pont)
<br />/, IC 5 v E 6 . 14 ,:-7. L - ' 5 F./`-�1-��1,C, .� A t) <. l /'.; TE>t�. - < y?, 1 7U /I,t- _,,,,4.-_--- t--,S S " C J
<br />326 REGISTRAR
<br />4i-4 C _
<br />320 DATE FILED BY REGISTRAR Mb. Day yrl
<br />! JEC 7 19
<br />•
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT ¢F Ji, . AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY 0kT115 IRIGijI , L'. C Pei) ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN/ RV-,TCESI.'VfT4i
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY f SAL RECORDS,. •. •
<br />DATE OF ISSUANCE
<br />MAY 202014
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT - NAME FIRST
<br />John Marion Simonson
<br />4. CITY AND STATE OF BIRTH *Arol0r US A. nannecoImepI
<br />_ Merrick County,
<br />7 SOCIAL SECURTIY NUMBER
<br />508 -46 -6464
<br />Z80 FACILITY - Name
<br />(0)
<br />Ic)
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Nebraska
<br />la 1414 ak5BAaotn, 954 sohyena n umbs*
<br />St. Francis Medical Center
<br />STATE OF NEBRASKA BOOK PAG��LQ
<br />201404983
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS e
<br />CERTIFICATE OF DEATH-
<br />MIDDLE LAST
<br />2 SEX
<br />Male
<br />5a AGE • Last Brredey UNDER I YEAR
<br />/Yrs l
<br />65 5 SD MOS ; DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ trpyanl
<br />Ea ER °weaken(
<br />❑ DOA
<br />UNDER t DAY
<br />_ 23
<br />....................... (£LATER ONLY ONE CAUSE PER LINE FOR ta). M). AND icp
<br />PART � } A : j,/ �J / {,
<br />1 �u C Ie.:
<br />C , (? - .,j a-L G�4 Ir�S1" v ► 'ls f.t LL.GYM �LrC rte.,. • f+�Ks.@
<br />gal la.. •
<br />■
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />:STANLgr 'B O R:
<br />ASSISTANT STAT FSTRAR
<br />,bEPARTMENT OF HEA'H AND
<br />HOOMAN SERVICES' `
<br />3 LDATE OF DEATH ma* Day real
<br />November 22, 1994
<br />6 DATE OF BIRTH 14444101 Day Year)
<br />94.13303
<br />Sc MOTS November 20, 1929
<br />OTHER L1 Nwsvg Home
<br />❑ Res4errt:e
<br />❑ Ober rSOecay,
<br />Interval between onset and death
<br />merval celween onset and aeon
<br />Interval Denman onset art dealer
<br />
|