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<br /> WHEYa' 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 DEP4��Q1�-�:�'Og
<br /> VITAL RECORDS. -= _- ---=
<br /> DATE OF ISSUANCE _ � _ _
<br /> ��� � �(��. STANLEY�� G`QOF�Ii,, D.�R�C'F�R
<br /> LINCOLN, NEBRASKA BUREAU OF_VI�A�-sT9��S��CS
<br /> STATE OF NEBfiASKA-DEPARTAAENT OF LTH
<br /> BUREAU OF VtTAL STATIST1CSr'�^ /-.,
<br /> CERTIFICATE OF DEATH J ��
<br /> 1.DECEDENT•NAYE FIRST MIDDLE UST 2.SO( 3.DA?E OF DEATH (Martlr,Day,Year/
<br /> Henry James Price Male November 19 1992
<br /> �.GTY AND STATE OF BIRTM (NnOfin U.SA,nuM eanbyl Sa ACaE•LYI&NMsy 8.DATE OF BIRTM /Mpr01,Day,YHr)
<br /> (Yro.) 5D. MOS.� DAVS Sc.HOURS� MINS.
<br /> Omaha, Nebraska 78 ; � October 5 1914
<br /> ?_�L�l SECVAITY NJMB�? 8a.PI,�CE OF OEAT!! H��� ❑� �ER/Ou�aEent ❑pOA
<br /> 505-10-7662 a or►�ea ❑N,u,„,qNw,,. o,+..;c„w. 0 on»,,s„�ar,
<br /> � B0.FACILITY•Nam� /Mnof iWYubn,ph�sqM ntl mmpr) &.CITY.TOWN OR LOCATION OF DEATH BE.INSIDE CITY UMITS B�.COUNTV OF DEATM
<br /> (Spec4y Yr a Nol
<br /> St. Francis Medical Center Grand Island Yes Hall
<br /> � Ya RESIDENCE-SfATE 9D.COUNTY 9c.CITY,TOWN OR LOCATpN 9Q STREET AND NUMBER /hdudirg Z(p CoO�J 9s.INSIDE CRY UMfTS
<br /> fSp�ciry vM a No)
<br /> Nebraska Hall Grand Island 824 W. 12th 68 O1
<br /> t0.RACE-(�.y.�MW�.Bbd�,M�cn Mai�n, 11.ANCESTRV(ap..MeNan.Msicfcan.Oarmm.Nc.) 12.MARRIED,NEVER MARRIED. 13.NAME OF SPOUSE (N wtl�,plw msidin narrNl
<br /> Me.)(��hl l�bl WIoOVVED.DNORCED/SpeMrl
<br /> White American ��v Married Catherine Dold
<br /> t1a USUAL OCCUPATpN/Giw kind d wvrlt darr Ounip maf - 146.KIND OF BUSINESS INOUSTRY -
<br /> a�wakuq Nhc�wr l nM�dl ENmentery a SecorMary 10-t 2) I CoN�ps�7 4 or 5•)
<br /> Switchman Telephone Com an N�� Unknown '
<br /> � �6.FAiHER-NA6E FIRST MIDDLE LAST 17.MOTHER•MAIDEN NAME FIRST MIDDLE LAST
<br /> Henry J. Price Geor ia NMN Unknown
<br /> � 18.WAS DECEAS�EVER IN U.S.AiN1E0 FORCES4 iB.INFORMANT•NAME-MAILING AODRESS �STREEf OR R.F.D.NO.,CRV OR TOWN,STATE,ZIP)
<br /> n.��o.«�.� �.,,�.,y�,�...,,m a.r,a.«�..� 68801
<br /> No -------- atherine Price, 824 W. 12th, Grand Island Ne.
<br /> 20a BURIAL,CremYon,Mrtqv�, 20D.DATE 20e.CEMETERY OR CREMATORY•NAME Z00.LOCATION CITY OR TONM STATE
<br /> Dorwlion
<br /> Burial Nov. 23, 1992 Westlawn Memorial Park Grand Island Nebraska
<br /> 21.E IMER- B1SE , 22.fUNERAI MOME-NAAIE AND ADDRESS �STREET OH R.F.D.NO.,CITV OR TOWN,STATE.ZIP�p�O�
<br /> 0
<br /> .S ivin ston-Sondermann 505 W. Koeni Grand I 1
<br /> 2 E I ER ONLY ONE CAUSE PER LJNE FOR�a�,�D�,AND(ep I IMsrv bs on�et�nE
<br /> PART
<br /> C C G�- !''P-� � � i�9/G l��S
<br /> DUE TO,OR AS A CAN WENCE OF: �! I Imerval bshroen onsst uW Mtlh
<br /> ' ��G��S11�2 C��''t�J�1q Q'� C'lC�� � � � � �
<br /> W E TO.OR A$A CONSEOUENCE OP: 1 Inbrval bslwesn onaN�nE GaM
<br /> / ;
<br /> e- . G%-- �'��
<br /> OTHE SIGNIFICANT ONDITI S-Condi�ona � to AeaM Dut nol relateC PART II IF FEMAIE,WAS TMERE A 21.AUTOPSY 25.WAS CASE REFERRED TO MEDICAL
<br /> PART PqEGNANCV IN THE PAST 3 MONTHS? (Spaeiy Ys a No� EXAMINER OR CORONER?
<br /> II
<br /> ves O No❑ � ���y r
<br /> 28t ACCIDENT,SUIGpE,MOMICIDE,UNOET., 2Bb.DATE OF INJURV /Mo.,Day,ri.) 28c.HOUR OF IWURY 26d.DESCRIBE MOW INJURY OCCU FED
<br /> OR PENDING INVESTKiATION /SysCily)
<br /> 28e.IWURV AT WORK 2&.PIACE OF INJURV-At home,ferm,sVeet,hctory, 28g.LOCATION STREET OR R.F.D.N0. CITY OR TOWN S?ATE
<br /> /SpselN Yn a Nol� alfics builCirp.Nc. /Spsc(N/
<br /> 27a DATE Of pEATH Ab.,pay,Yi.J 28a.DATE SIGNED (Mo.,Day.Yr.) 2BD.TIME OF DEATM
<br /> ��d 27D.DATE SIGNE ( ., y, r.J � 27 OF DEATM ��+� 28c.PRONOUNCED DEAD lMo..Qey.n.) 28d.PRONOUNCED DEAD /Hour)
<br /> � X / �2-: �22 ��`�
<br /> E� 270.70 of ,CeN a piaa a due B�� 2Be.On the buis of ecamination aM/a mvestigauon,in my opnion deaM occurred at
<br /> 1 � me ume,aaro ena v�ace a�a aw�o me ca�se�s�suua.
<br /> , ���� `�
<br /> �natwe anC Trcb
<br /> 29a.OID TO CCO USE CANT TO THE D TN7 30a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30p.WAS CONSENT GRANTED�
<br /> ❑VES ❑NO NKHOWN VES ❑N6 � O VES O
<br /> 31. A�SS OF HT�FIER�P Y C ER'S PHVS AN O�j OUN ATTORNEV) Ty �mt
<br /> HT i�.0
<br /> Q/ lL �� ' fG//"�!` � ����'i���/
<br /> 32a REGISTRAR 32b.DATE FILE DECST�iAR /Mp.,pqy,yr,J
<br /> • 2 [�7y%
<br /> NVL.
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