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IAMU& MOONS 0 MLQgeseae t3 DOA <br />Mew 0 New. Hem 0 RawWoo 0 Other AYPes+l77 <br />Nor mil RsM WR Ow pa * owIarrlSs •. ar . TOWN OP . • DON OF DEATH ate. MITTS <br />APO* <br />St. Francis Medical Center Grand Island 1 xea " ee « Al>J <br />- STATE' - !e. ✓,_. —. !t . TOMM Q11 LOCA1 O I STREET AND NUIMea tindrafte Av CA* <br />Nebraska Ball Grand Island 2304 W. Phoenix Ave. <br />IAMYI 11. - Ia..7lsMI Ma a.eR OemeerL MR.) n, �S wow). <br />@ =loan 0 1 <br />liblrodek 2K " '- ' —` tNiY" - <br />U.S. Government 1112 <br />t.a <br />mum. OOCUM►ne sem <br />it snow ea sem snows <br />U.S Postal Officer 0 <br />PATINA - NAME FWST <br />TS. WAS Obt yASED EVER d U.S. AIMED FORCES? <br />MaL ao.r umic( j IM ARIL !» _ rd IS M esevaa>.s1 <br />No <br />20a SURIAL, d NHANNAeassvY, <br />Donstan <br />Burial <br />SKNNATURE A <br />TO. OR AS <br />DUE TO, OR AS A CONSEQUENCE OF <br />PART SIGNIFICANT CONOTK s - Commons Mu nO b te dsM1 ON n0• Waled PART IN IF FEMALE, WAS THERE A <br />44L-41t / / q . ( PREGNANCY IN THE PAST 3 MONTHS? <br />'i tts�ttc `A .C = S j �� Yee 0 No 0 <br />°.h � •°+ .: _ 1 23. DATE CF voniaY n.) 26e. HOOP OF INJURY <br />OR PENDING INVESTIGATION Ppoo ti <br />20.. *NUM AT WORK 2M. PLACE OF INJURY - M home. Mme, I3.st <br />office buldino se0. (Saodcty) <br />ISEAreAy Ws or NO <br />3a REGISTRAR <br />unkno'n: <br />27a DATE OF .DEATH pack. Day, Yr.) <br />April 19, 1990 <br />276. DATE sow) INN, MA n.) <br />April 19, <br />27d. ToM beet Olray <br />careela1 1•eled. <br />and T • <br />AIL DID T YE USE <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT I -�44T ,AND , <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE QI1IG.IAtAL;kECQRD -W <br />. <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VS` ( 4Cr(2E,CQRQ'•. d a <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ;, . • ` • ,.; * ' <br />DATE OF ISSUANCE <br />APR 18 2014 <br />LI NEBRASKA <br />206. DATE <br />MIDDLE <br />Unknown <br />it 21, 1990 <br />a <br />Occurred et <br />THE DEATH? <br />ONLY <br />at i <br />27r.. TINE OF DEATH <br />STATE OF NEBRASKA M. DEPARTMENT OF HEALTH <br />E!1IIEEAUOF WIWM. SUM= =CB <br />c TE OF omit 4 I <br />LAST <br />Failing <br />lit **oakum. **oakum. - NAME - MAILING ADDRESS (STREET OW NQ,�Qy STATE. ZIP) <br />20e. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OR TOWN STATE <br />Grand Island Cemetery Grand island, Nebraska <br />22. FUNERAL E <br />RAL HO- NAME ANA. *OQRESS , (STREET OR R.F 0 NO,: CITY OR TOWN. STATE, 2W) <br />NE APfe1Butler- Geddes 1123 W. 2nd - Grand Island, NE 8801 <br />O PER UINE FOR h1. ro). ANO (e)i <br />LAST <br />9:49 AM rd Ms. <br />e doe a O and du lo ea. <br />STATE OF NEBRASKA <br />201405183 <br />John Wagoner M.D. 800 Alpha, Grand Island, NE. 68803 <br />S7`ANLEY C f_E!` <br />.TANT S ATE REG.! TRpR <br />'.`d 'OF HEALTH A•AIDr <br />Ball <br />be. NON E <br />xe. <br />XRES <br />is NAME OP SPOUSE rMeras srd•ANNW <br />Maxine A. Hales <br />1S w <br />EDUCATr1Y EMes.013oMalmY efeebir.d• <br />Oweenleff or �rd•r7 0112! I (1.4 o, s•1 <br />MI <br />17. MOTHER - MAIDEN NAME FIRST DDLE <br />Mabel E. <br />Maxine A. Failing -2304 W. Phoenix Ave. -Grand Island <br />1 24 AUTOPSY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />23.. DATE SIGNED DAY, Day, WI 200 TIME OF DEATH <br />PRONOUNCED DEAD MA Cey. Til <br />[,J HAS OR OR TISSUE DONATION BEEN � C / OI S*OERED? 30b. 41AS CONSENT GRANTED? <br />e� b NO Q UNKNOWN i u YES 34 0 / YES <br />31. NAYS AND ADOAESS OF COWMEN (PHYIICAN. COR314f9'S PIYSICAN OR COUNTY ATTORNEY) (Type 0, Poo0 <br />32b DATE FILED BY REAaSTFL R 1Mol t <br />Wow .(.ea <br />Mdrval bre.em Gags, mw death <br />Marv& Mow ciAsS eV deed) <br />25. WAS CASEERRFD TO MEDICAL <br />EXAMINER OR CORONER? <br />(50■04' YIN Of N,) <br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />!li 261e On en teals of .Yanwnalon antler ITIVutgaron, M my.oQarwon WOO occur*: at <br />, Ihe fam., dab and Otte end due b .1. Cewee(a) seised <br />ISeue re one Trey • <br />PRONOUNCED DEAD Mo t) <br />0 N <br />