|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH _
<br />SYSTEM IT' CERTWES THE BELOW TO BE A TRUE COPY OF THE ORIGANI l $1 b.�W$ji
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATtN,_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = _ --
<br />DATE OF ISSUANCE r
<br />NLEY &CO Q
<br />FEB 2 6 1998 200100233 _ _
<br />ASSWNIM STATE #W!STW
<br />LINCOLN, NEBRASKA HEALTH AND - 3YSTER
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYR jIKAWtESPORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />D ATE OF DEATH /Mort. Day. Year/
<br />Bernard Raphael Dunning
<br />Male
<br />�3- February 12, 1998
<br />a. CITY AND STATE OF BIRTH (Mno ilUSA.. name courtey)
<br />5a. AGE - Last Birthday
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mott. Day Year)
<br />Spalding, Nebraska
<br />(Vrs.l Sb.
<br />86
<br />October 24, 1911
<br />MOS. I DAYS
<br />T
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -07 -0943
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient � Residence
<br />8b. FACILITY -Name (Mnol institution. give sheet and number)
<br />3017 W. 16th St.
<br />1:1 DOA ❑ other(spec"y'
<br />Sc CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />C
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9C. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /IndudOgl Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />.{
<br />/
<br />2
<br />D
<br />C7
<br />11. ANCESTRY Is 9- Italian. Mexican. German, etc) /�
<br />12. g$ MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE lit wile. give maiden name)
<br />\
<br />I$peCi "' Irish /American
<br />Z
<br />N
<br />14a USUAL OCCUPATION (Give wind of work dote during most ^ _ . 1 1
<br />lit'e, d �llJf
<br /><b KIND OF BUSINESS INDUSTRY ` O
<br />1
<br />15. EDUCATION )Specify only highest grade completed)
<br />me Lary Sec ary 10 -121 College 11 4 o 5 -I
<br />tfi rot e
<br />of working even mfired) -]�1
<br />Truckdriver
<br />Trucking /Transport
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />John P. Dunning
<br />Margaret NMN Higgins
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT-NAME
<br />C►
<br />Mary 'Agnes' Dunning
<br />19b. INFORMANT MAILING ADDRESS (STREET CH R.F.D NO.. CITY OR TOWN STATE. ZIPI
<br />3017 W. 16th St., Grand Island, Ne. 68803
<br />20. EM L R; SIGNAT ;VSE O.
<br />21 a. ME1HOO OF DISPOSITION
<br />21 b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />rn >`
<br />o
<br />®Bu rial ❑Removal
<br />22a. FUNERAL HO NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATF
<br />Livingston - Sondermann F.H.
<br />❑Cemason ❑Donakon
<br />J
<br />Grand Island, Nebraska
<br />CZ)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />....
<br />�
<br />X ' (a) r ., i a
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contribu8rg to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 2
<br />r
<br />--c
<br />� r11
<br />D^ Cot
<br />°
<br />y
<br />EXAMINER OR CORONERS
<br />(Ages
<br />10 -54( Yes 0 No D
<br />Yes R No
<br />Yes H No
<br />26a
<br />26b. DATE OF INJURY (Mo. Day. Yc)
<br />o
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />r
<br />°
<br />�
<br />M
<br />S-Kie ❑ Pending
<br />26e. INJURY AT WORK
<br />co
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />r n
<br />Yes ❑ No ❑
<br />o8ce iINJURY
<br />06
<br />i
<br />27a. DATE OF DEATH (Mo.. Day Yr..)
<br />28a DATE SIGNED /Mo.. Day Yr)
<br />28b TIME OF DEATH
<br />N
<br />N
<br />CD
<br />r
<br /><
<br />27D DATE SIGNED /Mo.. Day Yr I
<br />27c. TIME OF DEATH
<br />28c PRONOUNCED DEAD IMO.. Day. Yr!
<br />2 .PRONOUNCED D AD IHOUq
<br />F
<br />Bib
<br />D
<br />W
<br />i
<br />/
<br />l/
<br />M
<br />g o
<br />27d. To the best of my knowledge, death occurred at the lime, date and place and due to the
<br />28e, r the basis o examination and invesbgalion, in my opinion death occurred at
<br />°
<br />°
<br />�7
<br />�.....
<br />N
<br />c
<br />time. dale and place and due tpaSe causelsl stated. .--7 -
<br />ISi nature and Title I►
<br />(Signature and Title 1�
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 36
<br />b WAS CONS T RANTED?
<br />X ❑ YES ❑ NO � UNKNOWN
<br />3
<br />`� ❑ YES JU NO .T
<br />Cn
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Pnnl
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH _
<br />SYSTEM IT' CERTWES THE BELOW TO BE A TRUE COPY OF THE ORIGANI l $1 b.�W$ji
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATtN,_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = _ --
<br />DATE OF ISSUANCE r
<br />NLEY &CO Q
<br />FEB 2 6 1998 200100233 _ _
<br />ASSWNIM STATE #W!STW
<br />LINCOLN, NEBRASKA HEALTH AND - 3YSTER
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYR jIKAWtESPORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />D ATE OF DEATH /Mort. Day. Year/
<br />Bernard Raphael Dunning
<br />Male
<br />�3- February 12, 1998
<br />a. CITY AND STATE OF BIRTH (Mno ilUSA.. name courtey)
<br />5a. AGE - Last Birthday
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mott. Day Year)
<br />Spalding, Nebraska
<br />(Vrs.l Sb.
<br />86
<br />October 24, 1911
<br />MOS. I DAYS
<br />Sc. HOURS' MINS.
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -07 -0943
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient � Residence
<br />8b. FACILITY -Name (Mnol institution. give sheet and number)
<br />3017 W. 16th St.
<br />1:1 DOA ❑ other(spec"y'
<br />Sc CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />Yes It No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9C. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /IndudOgl Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />3017 W. 16th St. 68803
<br />Yes 0 No ❑
<br />10. RACE - (e.g.. While. Black, American Indian.
<br />11. ANCESTRY Is 9- Italian. Mexican. German, etc) /�
<br />12. g$ MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE lit wile. give maiden name)
<br />etc.IISoeci N1 White
<br />I$peCi "' Irish /American
<br />MAKER D DIVORCED
<br />Mary 'Agnes' Whalen
<br />14a USUAL OCCUPATION (Give wind of work dote during most ^ _ . 1 1
<br />lit'e, d �llJf
<br /><b KIND OF BUSINESS INDUSTRY ` O
<br />1
<br />15. EDUCATION )Specify only highest grade completed)
<br />me Lary Sec ary 10 -121 College 11 4 o 5 -I
<br />tfi rot e
<br />of working even mfired) -]�1
<br />Truckdriver
<br />Trucking /Transport
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />John P. Dunning
<br />Margaret NMN Higgins
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT-NAME
<br />(Yes, no or unk.) I (If yes. give war and Oates of serviced
<br />no - - - - - --
<br />Mary 'Agnes' Dunning
<br />19b. INFORMANT MAILING ADDRESS (STREET CH R.F.D NO.. CITY OR TOWN STATE. ZIPI
<br />3017 W. 16th St., Grand Island, Ne. 68803
<br />20. EM L R; SIGNAT ;VSE O.
<br />21 a. ME1HOO OF DISPOSITION
<br />21 b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Feb. 16, 1998
<br />WestlaWn Memorial Park
<br />®Bu rial ❑Removal
<br />22a. FUNERAL HO NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATF
<br />Livingston - Sondermann F.H.
<br />❑Cemason ❑Donakon
<br />J
<br />Grand Island, Nebraska
<br />22D. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP(
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a) . (b). AND (c)l Interval between onset and death
<br />PART I
<br />X ' (a) r ., i a
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death
<br />I
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contribu8rg to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 2
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />y
<br />EXAMINER OR CORONERS
<br />(Ages
<br />10 -54( Yes 0 No D
<br />Yes R No
<br />Yes H No
<br />26a
<br />26b. DATE OF INJURY (Mo. Day. Yc)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />U Acadenl n Undetermined
<br />�
<br />M
<br />S-Kie ❑ Pending
<br />26e. INJURY AT WORK
<br />26f.
<br />E (, �A 1 , farm . street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />E] Homicide Investigation
<br />Yes ❑ No ❑
<br />o8ce iINJURY
<br />06
<br />27a. DATE OF DEATH (Mo.. Day Yr..)
<br />28a DATE SIGNED /Mo.. Day Yr)
<br />28b TIME OF DEATH
<br />_
<br /><
<br />27D DATE SIGNED /Mo.. Day Yr I
<br />27c. TIME OF DEATH
<br />28c PRONOUNCED DEAD IMO.. Day. Yr!
<br />2 .PRONOUNCED D AD IHOUq
<br />F
<br />Bib
<br />M�i0
<br />i
<br />M
<br />g o
<br />27d. To the best of my knowledge, death occurred at the lime, date and place and due to the
<br />28e, r the basis o examination and invesbgalion, in my opinion death occurred at
<br />°
<br />causelsl stated.
<br />°
<br />time. dale and place and due tpaSe causelsl stated. .--7 -
<br />ISi nature and Title I►
<br />(Signature and Title 1�
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 36
<br />b WAS CONS T RANTED?
<br />X ❑ YES ❑ NO � UNKNOWN
<br />3
<br />`� ❑ YES JU NO .T
<br />❑ YES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Pnnl
<br />32a FWGISTRAR
<br />32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.)
<br />'- I
<br />FEB 2 51998
<br />A tract of land comprising the Easterly Twenty -Eight
<br />(28.0) feet of Lot Two (2), and the Westerly Twenty -Eight
<br />(28.0) feet of Lot Three (3), Franzen Subdivision, a
<br />
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