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1 DECEDENT - NAME FIRST MIODLE LAST <br />Samuel Fredrick Bowers <br />2 SEX - k <br />Male <br />3. DATE OF DEATH (Month. Day. Year) <br />April 1, 2000 <br />14. CITY AND STATE OF BIRTH (I( not in US A. name country) <br />Merrick County, Nebraska <br />5a. AGE - Last Birthday <br />!Yrs.) <br />80 <br />UNDER 1 YEAR <br />UNDER i DAY <br />6. DATE OF BIRTH (Month. Day Year) <br />February 17, 1920 <br />50 MOS. I DAYS <br />i <br />5c. HOURS MIN <br />7 SOCIAL SECURTIY NUMBER <br />508 -07 -6622 <br />8a. PLACE OF DEATH <br />HOSPITAL: L <br />❑ <br />❑ <br />Inpatient OTH_E_R ❑ Nursing Home <br />ER Outpatient ❑ Residence <br />DOA ❑ Other ispeci(r <br />Bb. FACILITY - Name //fool Institution. give street and number) <br />St. Francis Medical Center <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d. NSIOE CITY LIMITS <br />Yes [i No ❑ <br />8e. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />96. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (including Zip Cale) <br />516 N. Darr 68803 <br />9e INSIDE CITY LIMITS <br />Yes 11 No ❑ <br />10 RACE - (e.g., White. Black. American Indian. <br />etc.) (SdeCdy) White <br />11. ANCESTRY (e.g.. Italian. Mexican. German. etc( <br />ISpec45! American <br />12. Gii MARRIED <br />NEVER <br />R: <br />MA D <br />❑ WIDOWED <br />.DIVORCED <br />13. NAME OF SPOUSE Rf w6e give ma den name) <br />Edna M. Faustman McDaniel <br />14a. USUAL OCCUPATION /Give kind of work done during most <br />of working fife. even if retired( <br />Electrical Operator <br />14b. KIND OF BUSINESS INDUSTRY <br />Power Plant <br />15. EDUCATION (Specify only highest grade completed' <br />etiry INGradre College H.4 nr5•I <br />16. FATHER - NAME FIRST MIDDLE LAST <br />Lawrence Bowers <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Mary Steinbeck <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yes. no. or unk.) III yes. give war and dates of services) <br />1 Yes ' WWII 11- 6- 1941/10 -16 -1945 <br />19a. INFORMANT • NAME <br />Edna Bowers <br />E <br />R _ <br />U " <br />Et <br />29 DID <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND DES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REV OD ON` FILE ,WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC SEC TJON,_WHICtt IS- <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />(6) <br />APR 7 2000 <br />LINCOLN, NEBRASKA <br />196 INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI <br />516 N. Da r, Grand Island, Nebraska 68803 <br />StGNAT LICNNS5 NO <br />r1 <br />ME <br />DUE TO, OR AS A CONSEQUENCE OF <br />i_- lc1 <br />( <br />PART <br />11 <br />26a <br />!Accident Undetermined <br />Suic,de Pending <br />Homicide Investigation <br />2 0 15 0 2 5 3 ANL Y4 &COOPER <br />ASSISTANT STATE REGISTRAR <br />HEALTH AND HUMAN SERY#EESY4TEMt= <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVInF-C'FINANCE ' ID STIPPORT <br />ITAL <br />V STATISTICS - <br />CERTIFICATE OF DEATH <br />21a. METHOD OF DISPOSITION 21b. DATE <br />Bunn' El Removal <br />Livingston -Sonde I ann F.H. ❑Cremation ❑Donation <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIPI <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATESAUSE )ENTER,( OILY ONE CAUSE PER LINE FOR la). MI. AND (dI) <br />� PART L 11 <br />DUE TO. OR AS A CONSEQUENCE OF <br />Grand Island, Nebraska <br />31.. N N -N AD <br />AME AND DRESS OF CERTIFIER (PHYSICIAN, CORONER a S PHYSICIAN 014 COUNTY ATTORNEY) (Type Print) <br />{ GORDON J HRNICEK M.D. 729 N Custer, Grand ISLAND, NE 68803 <br />■ 4414 4 - <br />32a. REGISTRAR <br />21c. CEMETERY OR CREMATORY - NAME <br />Apr. 5, 2000 Westlawn Memorial Park <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Interval between onset and cream <br />_, <br />Interval between onsetAnd death <br />Interval between onset and death <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />TOBACCO USE CONTRIBUTE TO THE 0 <br />❑ YES N0 <br />265. DATE F INJURY (Mo.. Day. Yr( <br />33 -fzoac <br />26e. 6001411 AT W ORK <br />Yes I 1 No <br />27a. DATE OF DEATH /Mo.. Day Yr.) <br />27d. To the best of my knowledge death occurred <br />k 03058)5) stated. <br />)signature and Ti11eJ ► <br />27b. DATE SIGNED Y Mn. Day Y ) 27c. TIME OF DEATH <br />i / / <br />26c: HOUR OF INJURY <br />261 PEACE OF INJURY - At home. farm .. street factory <br />06108 but ng etc. /Speco54 <br />e time. date and place and due to me <br />PART 111 IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10 -54) Yes n No ❑ <br />26d. DESCRIBE HOW INJURY OCCURRED <br />'1 I <br />26g. LOCATION STREET OR R.F.D. NO <br />16 Ai, r <br />28a. DATE SIGNED (MO.. Day. Yr) <br />28c. PRONOUNCED DEAD (Mo. Day. Yrl <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />"� ❑ YES NO <br />24. AUTOPSY <br />y Yes n No <br />285. <br />28d. <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />S n No <br />006 OR TOWN STATE <br />TIME OF DEATH <br />PRONOUNCED DEAD (Hour) <br />28e. On the basis 01 examination and or inveShgatinn. In my opinion death Occurred at <br />u a ' the time, date and place and due to the cause's stated. <br />(nature and Title) • <br />30.5 WAS CONSENT GRANTED?. <br />- ❑ YES NO <br />321 DATE FILED BY REGISTRAR (Mo. Day. Yr) <br />APR 6 2000 <br />M <br />