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<br /> NMEN THIS COPY C�ES TF�RAISED SEAL OF THE NEBF ASKA HEALTH AND HUMAIV SERNCES
<br /> SYSTEII�IT CERTIFAES THE BELOW TO BE A TRUE COPY OF THE OR/G/NAL REC�E��TH
<br /> � THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL STATIST/C�5�.��4
<br /> = _ _ - -
<br /> THE LEGAL DEPOS/TORY FOR V/TAL RECORDS ,_ _
<br /> := ... .. _::,.,,,;�qY'�'�!=t.,,+n„r i t
<br /> . . -. _ ._ . _ ._ - .,_ . _ ._
<br /> .: �b0�t�+��� _- . .
<br /> DATE OF 13SUANCE , _=
<br /> � A�"��c�ioP�. -
<br /> AUG 171999 Ass�s��-� - -- - �=_ _
<br /> LINCOLN,NEBRASKA HEALTH AND H111�@ 3FRUjE'„E3 SYSTEIif -- ��-
<br /> S'CATE OF NEBRASKA-DEPAR2'MENf OF HEALTH AND HUMAN SERV�ES F��S[Jppp� �
<br /> V1TAI,STATLSI'ICS -_ --_ --- � -_
<br /> CERTIFICATE OF DEATH =- ` '--=
<br /> 1 DECEOENT�NAME FIRST MIDDLE LAST 2 SEX �_�F DEATH /Monlh.Day.Yee�l
<br /> Tannies John Waller Male August 11, 1999
<br /> 4 CITV AND STATE OF BIR7H /Ilnpfn USA..name counhyJ Sa.AGE-Last Birthday UNDER 1 VEAR UNDER t DAV 6.DATE OF BIRTH /MonM.Day Year/
<br /> Holdrege, Nebraska ���� 85 SD MOS � DAVS Sc HOURS' MWS November 25, 1913
<br /> 7.SOCIAL$ECURTIV NUMBER Ba.PLACE OF DEATH
<br /> 508-12-4529 HOSPITAL � Inpatient OTHER � Nurg�ng Mome
<br /> Bb.FACILI7V-Name (Hnpf�nstifNqn,giw shBef aM num6M/ � ER OutpaGenl � Residence
<br /> St. Francis Skilled Care ❑ �A ❑ a„,,,S�,ty,
<br /> & C�TV TO�NN OR LOCATION OF OEATH� 8d.INSIDE CITV LIMITS Be COUNTV OF DEATM
<br /> Grand Island • ,,,� � No ❑ Hall
<br /> 9a.RESIDENCE-STATE ffi.COUNTV 9C.CITV.TOWN OH LOCATION 9d.STREET AND NUMBER /Int/uding 1 p Code/ 9e INSIDE CITV LIMITS
<br /> ivebraska Hall �- ' GYanc�tZs��iic4'� ` 17II3 S. Arthur 68803 �es X� �w�
<br /> 10.RACE-(s.g.,White.B1ack.American Intlian. 11.ANCESTRV le.q..Malian.Maxiqn,GHm�n,Mtl 12.n MARRIED ❑WIppWED 13.NAME OF SPOUSE llI wde.givB maiden name/
<br /> NcIiS
<br /> ISpxMI
<br /> °1�f'►ite American � NEVER OIVORCED Esther E. Murrish
<br /> MAR
<br /> 11a.USUAL OCCUPATION /Grve kiMd wwk dd�sOwing mosf 1�b.KIND OF BUSINESS INDUSTRY 15.EDUCATION �Spgaty only Mgheet gratle compbted�
<br /> dwoikmg/ile,even i�reliredl Elemen�rV or Secoryary 10-t21 College I�-a or 5-i
<br /> Technician Bureau of Reclamation 2
<br /> 7b.FA7HER.NAME _.J9S7_____._ AdlQQLE lAST n MpTMF.a ._. �FIRgi. NWpt€ -'_.- -r-,��ry6yc�ppSUqNAME-.'--
<br /> John Waller Christine Johnson
<br /> 7B.W�S LECEASED EVER W U.S.ARMED PORCES? 19a.INFORMANT-NAME �
<br /> Yes:�u"��W.W;°I��'"ewar2 17��42' 1-28-46 Esther E. Waller
<br /> 190.!NFORMANT MAILING ADORESS ISTREET OR R.F.D.NO..CITV pR TOWN.STATE.21P)
<br /> 1703 S. Arthur, Grand Island, Nebraska 68803
<br /> 20.EMBAL -SI TUA 8 ENSE NO. 21a.METHOOOFDIS�TION 27b.DATE 2tc.C"cMETERV OR CFlEMATOA��NAME
<br /> ,�
<br /> � / t 0���.� �Removal Ang. 14, 1999 Westlawn Memo�sial Park
<br /> 22a.fU ERAL HO E-NAME 210.CEME7ERY OR CREMATORV LOCA710N CITV OR TOWN STATE
<br /> Apfel-Butler-Geddes ❑��•^�^ ❑�^a�a^ Grand Island, Nebraska
<br /> 22p.FUNERAL HOME ADDFiESS ISTREET OR R.F.O.NO..CITV OR TOWN.$TATE,ZIP�
<br /> 1123 West Second, Grand Island, Nebraska 68801
<br /> 2J. iMMEDIATE CAUSE , . �ENTER ONLV ONE CAUSE PER LINE FOR ial.Ib1.AND�c�) I Interval betwean onset antl tlealn
<br /> PAFT I
<br /> � ��t.c�N� G�.11,v ��u r i ./� � 3 Yrt.S
<br /> ,a� ,
<br /> DUE T0.OR AS A CONSEOUENCE OF� _ i Interval Datween onsel antl tleam
<br /> I
<br /> Ibl �
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<br /> DUE TC.OR AS A CONSEOUENCE OF�. I Inlerval between onset antl tleaM
<br /> I
<br /> �t� 1
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<br /> PARr OTHER SIGNIFICANT CONDITIONS•COrMiGons COMlibuGfq lo Ille OeeM bul nd r91a�9tl PART 111 IF FEMALE.WAS TNERE A 20 AUTOPSV Z5.WAS CASE REFERRED TO MEDICAL
<br /> II PREGNANCV IN THE PAST 3 MONTNS? EXAMINER OR CORONER�
<br /> IAgas�0-Sa� ves nlo ves No - Ves No
<br /> 26a. 26b.OATE Of INJURV /Mo..Day.YcJ 2&.HOUR OF INJURY 26d.DESCRIBE HOW INJURY OCCURRED
<br /> � Acutlent � Undelerminetl M .
<br /> � Su�rde � Pe�d��g 26e.INJURY AT WOAK '281.PLACEOF,INJURY-/�t Ii071y;4rm.rreg�.factory" 26g.LOCATION STqEET QR R F.D.NO. CI7V dF TOWN � STA7E
<br /> ❑ ❑ ❑ oMice buibing.etc. /Speeey/ ,
<br /> �.m�cWe tnvestganon Ves No
<br /> 27a DATE OF DEATH /Mo.Day.Yr.1� 28a OATE SIGNED /Mo.Day vr.i 2Bb 71ME OF DEATH
<br /> /`
<br /> �3- 11- 1q`t1 ar
<br /> a< a-Q M
<br /> �� 27p.DATE SIGNED /Mo.Day Yr.l 27a TIME OF DEATM ��} 2&.PRONOUNCED DEAD /Mo..Day,Yc� 2BA.PRONOUNCED DEAD /hburl
<br /> � -iz -S'� 3` c� A ����
<br /> 8� 6A 8 � M
<br /> 27tl.To�Ile blS�01 my knOwbtlg.d!8 OCCurrW a� IB •UW du@ t0�118 ��� 2g¢.On Me Dasis of ezaminatbr+and�a mvestigauon.in my oqrnon aeatn«curred at
<br /> causelsl statetl. r a the time,dare and pace and tlue to ma cause�sl s�aled.
<br /> �Si naWre and Tflle� �&naNre anC Tille
<br /> 29.DID TOBACCO USE CONTRIBUTE T TME DEATN7 30.a M S ORGAN OA TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED7
<br /> � VES �NO � UNKNpWN � VES �NO_ � VES
<br /> T
<br /> 31 NAME AND ADDRESS OF CERTIFIER fPHVSICIAN,CORONER'S PHVSICIAN OR COUNTY AiTORNEVI lType a Pimp -
<br /> David R. Colan M.D. 729 N. Custer, Grand Island, Nebraska 68803
<br /> 328.REGISTRAR 32b.DATE FILEO BY REG�STRAR (Mp..Day.YcJ I
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