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I. DENT - NAME FIRST MIDDLE LAST Paul (NMN) Manolidis 2 SEX - Male 3. DATE OF DEATH (Month Day. Year) December 10, 1998 AND STATE OF BIRTH (d not in USA.. name country/ 5a. AGE - Last Birthday (Y s.) 78 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (MO091, Day. Year/ March 13, 1920 __ .._ins, West Virginia DAYS sc: HOURS MANS 4 7. SOCIAL SECURTIY NUMBER 1 235 -20 -1990 8a. PLACE OF DEATH HOSPITAL: 0 Inpatient OTHER: ❑ Nursing Home ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other speoty, i 6b. FACILITY - Name 111 not institution, give street and number) 1 1 St. Francis Medical Center 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS Yes 710 ❑ 8e. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CRY, TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 2209 N. Sheridan Street, 68803 9e. INSIDE CITY LIMITS Yes No ❑ 10. `: RAACE - (e.g., White. Black. American Indian. W I /TIC 1tr1 11. ANCESTRY le.g.. Italian. Mexican, German, etc) A Qr 1230 MARRIED ❑ WIDOWED n El NEVER E DIVORCED j.....1 MARRIED L-� 13. NAME OF SPOUSE Ill wile. give maiden name) Phyllis Boroff 140. USUAL OCCUPATION (Give kind await done during most ' 1 d 11 working hie. eve i7 retired( 1 -- Optician 14b. KIND OF BUSINESS INDUSTRY D 15. EDUCATION (Specify only highest grade completed) �p Grand Island Optical Elementary Or Secondary 10 -12) College It -a or 5•I 12 2 18. WAS DECEASED (Yes. no. or unk.) Yes EVER IN U.S. ARMED FORCES? (0 yes. give war and dates 01 services 06/06/ 1942- - I Wo War II 12/22/1945 19a INFORMANT - NAME Phyllis N. Manolidis 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. 2IP) 2209 N. Sheridan, Grand Island, Nebraska 68803 20. EMBAL i - -. NATO- ' O. .0 4/ _ 21a. METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation ❑ i 215. DATE - 12/12/1998 210. CEMETERY OR CREMATORY - NAME Westlawn Memorial Park Cemetery 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Grand Island, Nebraska 22a. FUNERAL HOME AME Apfel- Butler - Geddes Funeral Home 221. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.: CITY OR TOWN. STATE, ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 II DUE TO, OR Pr ON In bet and death lJJ� / 5 DUE TO, 0* A CONSEOUENCE OF: (v) it / V b Interval between onset and death OTHER SIGNIFI • DIT S - Conditions contributing to the death but not related PART / (�� .X t J1 REGNANCY 9 1� �/ � � V ` w`' " • r 1 11 ` ""`� -' `. PART 10 IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? (Ages 10-541 Yes n No n 24. AUTOPSY Yes n No V 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Yes n No RI 26a. 0 Accident 1111 Undetermined 1 Suicide 0 Pending 1 Homicide Investigation 26b. DATE OF INJURY Mo.. Day. YrJ - 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e INJURY AT WORK yes ❑ No ❑ 1:14 E OF ill Y -AZT?. term. street. 261. sp ffic bu'M ecir37 26g. LOCATION STREET OR R.F.D. NO. CilV OR TOWN ` J STATE • 27a. DATE OF DEATH (Ma. Day. Yr.) / a- /o - 9 Da A1N0 A3Ntl011Y AJNflO O NY105ANd S.133N080O Aq DePOLuoJ aq 0 1 28a. DATE SIGNED (and.. Day. Yc) 285. TIME OF DEATH WINO OISANd MA U* aq 01 y 'r'!�W 27b. DATE SIGNED (MO.. Day. Yr./ Ice- 1 - qe 27c. TIME OF DEATH 5. A M 28c. PRONOUNCED DEAD (Mo.. Dag Yc) 28d. PRONOUNCED DEAD (Howl 27d. To the best of my knowledge. cwRad at the 6me, date and place and due to the meets) stated (Signature and Title) ► '" ` 28e. On the basis of examination and investigation, in my opinion death occurred al , - the time, date and pace and due to the causes stated. (Signature and Title) ► - 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO 0 UNKNOWN . S0. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES A NO 30.b WAS CONSENT GRANTED? ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) Dr. Richard M. Fruehling, 2116 W. F idley Ave. St # 1 , Grand Island, Nebraska 68803 32a. REGISTRAR ti' �" • 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) DEC 16 1998 16. FATHER - NAME 4 WHEN THIS COPYCARRE:S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA, ERVICES, SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD OFIkILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECT! • 1CJI IS - THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE DEC 1 81998 LINCOLN, NEBRASKA Chris FIRST MIDDLE 201408072 LAST Manolidis ASSISTANT ST HEALTH AND HUMAN SE STATE OF NEBRASKA- DEPARTMENT OF HEALTH HUMAN SERVICES VITAL STATISTICS CERTIFICATE OF DEATH 17. MOTHER Florence 23. IMMEDIATE CAUSE TENT R ONLY ONE CAUSE PER UNE FOR (a6 (b), AND lo)) ) PART 5 51611/ ( IS I lal FIRST MIDDLE MAIDEN SURNAME Lloyd