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WHEN THIS COPY CARWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND k1aCES <br />SYSTEM, R CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST . <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />�Q��jj <br />22 22Qaa'�� 200101544 <br />, RE JAW ASS/i� <br />LIMAiA l STATE ]RE <br />HEALTH AND <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEWWa RT <br />VITAL STATISTICS 00337 <br />CERTIFICATE OF DEATH ' _~= <br />CEOEN7NAME FIRST MIDDLE LAST 2 SEX. 3 DATE OF.OEATH tMomh. Day Year) <br />Lynn David Sweeney Male January 12 <br />Y AND STATE OF BIRTH /q riot in US.A.. name country) 5a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 16 . DATE OF BIRTH /Month. Day. Year/ <br />M e r N b (Yrsl 5b MOB DAYS Sc HOURS MINS <br />cn cn <br />c a <br />2 Tel <br />-< O <br />o `I <br />'*1 z: <br />z M <br />D cn <br />r � <br />r n <br />D <br />� <br />W'^ <br />Cn <br />a raska <br />75 <br />24 AUTOPSY <br />9c CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER oncluding Zip Code) --- <br />811 W. 16th St.68801 <br />19 <br />MBER <br />8a. PLAC E OF DEATH <br />rn <br />n <br />13 NAME OF SPOUSE Ill wife. give maiden name/ <br />rSECURTtY <br />-695 <br />(Specify) <br />American <br />HOSPITAL <br />n <br />Z <br />Inpakenl OTHER <br />> <br />CD <br />MARRIED <br />7c <br />M <br />cis Skilled Care <br />(1 <br />Of working even d /etlred) <br />v Re istered Nurse <br />Hos ital <br />Elementary or Secondary (0 -12) College 11 -4 or 5 - i <br />12 <br />(D <br />LAST 17 MOTHER <br />3 _ <br />FIRST MIDDLE MAIDEN SURNAME <br />Edward James <br />1A w4c ncrceccn ❑u w uc eo cnonocn <br />Sweeney <br />I ,._ ,. .. <br />DOA <br />other (Spec,fy, <br />8c. CITY TOWN OR LOCATION OF DEATH <br />8d <br />-4- <br />Be. COUNTY OF DEATH <br />- -- <br />m <br />CD <br />En <br />3 <br />Hall <br />27a TIME OF DEATH <br />2 &. PRONOUNCED DEAD (Ma. Day. I <br />28d. PRONOUNCED DEAD /Hour! <br />_ <br />/ (J' <br />:3 <br />° <br />° a <br />M <br />27d <br />27tl To the 51 of my kno letlge death acun t nd tlue to the <br />causes) stated. <br />28e. On the basis of examination and'or Investigation, in my opinion death occurred at <br />the time. date and place and tlue to the causels) stated, <br />ISi nature and Title) <br />atime.nd <br />29 DIO TOBACCO USE CONTRIBUTE TO iH jDEATH7 <br />1. <br />S ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />9 VES NO 0 UNKN <br />YES n NO <br />YES I VI NO <br />31 NAME AND ADORFSC nF rPPTIFIFR IPUV CV`reu r•nonnieo c euvcrnieu <br />n� .... .,r....t......�.., ,- - _ <br />WHEN THIS COPY CARWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND k1aCES <br />SYSTEM, R CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST . <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />�Q��jj <br />22 22Qaa'�� 200101544 <br />, RE JAW ASS/i� <br />LIMAiA l STATE ]RE <br />HEALTH AND <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEWWa RT <br />VITAL STATISTICS 00337 <br />CERTIFICATE OF DEATH ' _~= <br />CEOEN7NAME FIRST MIDDLE LAST 2 SEX. 3 DATE OF.OEATH tMomh. Day Year) <br />Lynn David Sweeney Male January 12 <br />Y AND STATE OF BIRTH /q riot in US.A.. name country) 5a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 16 . DATE OF BIRTH /Month. Day. Year/ <br />M e r N b (Yrsl 5b MOB DAYS Sc HOURS MINS <br />cn cn <br />c a <br />2 Tel <br />-< O <br />o `I <br />'*1 z: <br />z M <br />D cn <br />r � <br />r n <br />D <br />� <br />W'^ <br />Cn <br />a raska <br />75 <br />24 AUTOPSY <br />9c CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER oncluding Zip Code) --- <br />811 W. 16th St.68801 <br />19 <br />MBER <br />8a. PLAC E OF DEATH <br />12. ©MARRIED <br />❑ WIDOWED <br />13 NAME OF SPOUSE Ill wife. give maiden name/ <br />rSECURTtY <br />-695 <br />(Specify) <br />American <br />HOSPITAL <br />DIVORCED <br />Inpakenl OTHER <br />® Nursing Home <br />ltr nol,nsttution, give street and number/ <br />MARRIED <br />ER Outpatient <br />F1 Residence <br />cis Skilled Care <br />_ <br />15. EDUCATION ISpecity only highest grade completed( <br />Of working even d /etlred) <br />v Re istered Nurse <br />Hos ital <br />Elementary or Secondary (0 -12) College 11 -4 or 5 - i <br />12 <br />16. FATHER -NAME FIRST MIDDLE <br />LAST 17 MOTHER <br />3 _ <br />FIRST MIDDLE MAIDEN SURNAME <br />Edward James <br />1A w4c ncrceccn ❑u w uc eo cnonocn <br />Sweeney <br />I ,._ ,. .. <br />DOA <br />other (Spec,fy, <br />8c. CITY TOWN OR LOCATION OF DEATH <br />8d <br />INSIDE CITY LIMITS I <br />Be. COUNTY OF DEATH <br />- -- <br />Grand Island <br />Yes n Nd n� <br />Hall <br />27a TIME OF DEATH <br />ga RESIDENCE - STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />24 AUTOPSY <br />9c CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER oncluding Zip Code) --- <br />811 W. 16th St.68801 <br />9e INSIDE CITY LIMITS <br />Yes No <br />10 RACE leg., White. Black. American Inman <br />11. ANCESTRY le.g.. Italian, Mo,rcAn. German, etc/ <br />12. ©MARRIED <br />❑ WIDOWED <br />13 NAME OF SPOUSE Ill wife. give maiden name/ <br />etc I'Spec"1 <br />White <br />(Specify) <br />American <br />NEVER <br />DIVORCED <br />- -✓ SGi;W3- IGiV iH`ksR'r i+cGURHEV - -._ <br />Accident Undelermmed <br />MARRIED <br />Mar Lou Lindl <br />14a 'USUAL OCCUPATION fl; V kd <br />mot worA done during most <br />life <br />14b. KIND OF BUSINESS INDUSTRY <br />_ <br />15. EDUCATION ISpecity only highest grade completed( <br />Of working even d /etlred) <br />v Re istered Nurse <br />Hos ital <br />Elementary or Secondary (0 -12) College 11 -4 or 5 - i <br />12 <br />16. FATHER -NAME FIRST MIDDLE <br />LAST 17 MOTHER <br />3 _ <br />FIRST MIDDLE MAIDEN SURNAME <br />Edward James <br />1A w4c ncrceccn ❑u w uc eo cnonocn <br />Sweeney <br />I ,._ ,. .. <br />Delia Kaelin - __- <br />(Yes. no .y unk.) 111 yes give war and gales of services/ WW I I <br />Yes Jun 20 19 6 -Nov15 194h Mary TOIL �WPAney <br />190 INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN STATE. ZIPI - -- <br />20.E LMER -SIGN UVLICE�� -21 a. METHOD OF DISPOSITION 72110E E 21c CEMETERY OR CREMATORY NAME <br />�7 l07� ®Burial 11 Removal . 15 2001 New Helena Cemetery <br />a FUNERAL HOME NAME METERY OR CREMATORY LOCATION CI iV OR TOWN $TFTE <br />All Faiths Funeral Home ❑Cremation 11 Donator Anselmo Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) - -- <br />2929 S. Locust St. Grand Island Nebraska 68801 <br />23 PART IMMEDIATE CAUSE /_ (ENTER ONLY ONE CAUSE PER LINE FOR ,al Ibl. AND Icll Interval between onset and deem <br />I tai � '�1�.�✓y I /LJ C�� II✓1.�� <br />IN <br />o <br />N <br />O <br />CD <br />CD C <br />F—+ <br />Ul <br />r-- <br />f <br />V <br />J <br />U <br />U <br />V) <br />1 <br />Y <br />I Interval boolsen onset and death <br />I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death bIA rid related PART <br />PART <br />III IF FEMALE WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />II PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER'/ <br />(Ages 10 -541 Yes No <br />Yes No <br />Yes No <br />,,, LA 7E OF INJURY (Mo., Day. Y.) <br />24;. OUR OF BVJURY -- <br />- -✓ SGi;W3- IGiV iH`ksR'r i+cGURHEV - -._ <br />Accident Undelermmed <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />26T. PLACE QF INJURY - At home, /arm. skeet. factory <br />o ice building. etc /Specify) <br />26g. LOCATION STREET OR q F D. NO CITY OR TOWN STATE <br />Homicide Investigation <br />Yes No <br />❑ O <br />27a DATE OF DEATH /Mo Div Yr.) _ <br />28a DATE SIGNED (Mo. Day Yrl <br />28b TIME OF DEATH <br />z C) / <br />r <br />M <br />27b. DATES IG ED ( Day Yr /\ <br />/ <br />27a TIME OF DEATH <br />2 &. PRONOUNCED DEAD (Ma. Day. I <br />28d. PRONOUNCED DEAD /Hour! <br />/ (J' <br />:3 <br />° <br />° a <br />M <br />27d <br />27tl To the 51 of my kno letlge death acun t nd tlue to the <br />causes) stated. <br />28e. On the basis of examination and'or Investigation, in my opinion death occurred at <br />the time. date and place and tlue to the causels) stated, <br />ISi nature and Title) <br />atime.nd <br />29 DIO TOBACCO USE CONTRIBUTE TO iH jDEATH7 <br />1. <br />S ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />9 VES NO 0 UNKN <br />YES n NO <br />YES I VI NO <br />31 NAME AND ADORFSC nF rPPTIFIFR IPUV CV`reu r•nonnieo c euvcrnieu <br />n� .... .,r....t......�.., ,- - _ <br />�Ot-' <br />328. REGISTRAR <br />JY HEGISTRAR /MO., Day YiJ <br />JAN 19 2nnf <br />i <br />J <br />Q <br />a <br />M <br />J <br />