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DECEDENT -NAME MIST MIDDLE LAST
<br />1 . Olive Norene Cimino
<br />SEX
<br />2 Female
<br />DATE OF DEATH (Ma.. Doy. Yr.)
<br />3. November 6, 1986
<br />RACE - (e.g., White, Block, American
<br />Indian, ek.) (Specify)
<br />4. White
<br />ORIGIN /DESCENT (e.g., Italian, Mexican,
<br />German, etc.) Specify)
<br />s. American
<br />AGE -Lost Birthday
<br />(Yrs.)
<br />6a_ 62
<br />UNDER 1 YEAR UNDER I DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />7 .January 20, 1924
<br />MOS. . DAYS
<br />6b.
<br />HOURS : MINS.
<br />I Ac.
<br />CITY AND STATE Of BIRTH (If net in U.S.A.,
<br />name eounky)
<br />B. Walker, Missouri
<br />CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED (Specify)
<br />9. U.S.A. 1 Married
<br />NAME OF SPOUSE (If rife, give maiden name)
<br />11 Angelo J. Cimino
<br />SOCIAL SECURITY NUMBER
<br />12. 508 -05 -1700
<br />USUAL OCCUPATION (Give kind of work done during most
<br />of working life, even if retired)
<br />13a. Homemaker
<br />KIND OF BUSINESS OR INDUSTRY
<br />13b Own Home
<br />COUNTY OF DEATH
<br />)4a. Hall
<br />CITY, TOWN OR LOCATION OF DEATH
<br />146. Grand Island
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />14c. Yes
<br />HOSPITAL OR OTHER INSTITUTION - Name (If not in either,
<br />give street and number)
<br />14d. St. Francis Medical Center
<br />If HOS? OR INST. Ind■cat. DOA.
<br />Outpet)ent!Emer Ron inpatient (Specify)
<br />14. Emergency Room
<br />RESIDENCE -STATE COUNTY
<br />1sa. Nebraska 1sb. Hall
<br />CITY, TOWN OR LOCATION
<br />1St. Grand Island
<br />STREET AND NUMBER
<br />1Sd. 2003 W. John
<br />INSIDE CITY LIMITS
<br />(Specify es or No)
<br />Is ' Yes
<br />FATHER -NAME FIR T MIDDLE LAST
<br />16 Bruce Frank Colin
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />17 Ola May •Culbertson
<br />WAS DECEASED
<br />(Yes. no, ar insM
<br />18. No
<br />EVER IN U.S. ARMED FORCES?
<br />(It yes. give war and donn of rain)
<br />I - --
<br />INFORMANT - NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR Rf 0 NO.. CITY OR TOWN, STATE. ZIP)
<br />19Angelo Cimino(pus) 2003 W. John, Grand Island, Ne.6880:
<br />BURIAL, Cremation, Removal
<br />20o. Burial
<br />DATE
<br />2ob.Nov. 10,1986
<br />CEMETERY OR CREMATORY- NAME
<br />20c. Grand Island City Cemetery
<br />LOCATION CITY OR TOWN STATE
<br />god. Grand Island, Nebraska
<br />EMBALMER - SIGNATURE d LICENSE NO.
<br />� a 44
<br />�
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIPI 6
<br />22Livingston- Sondermann 505 West Koenig, Grand Island, N
<br />4
<br />lu
<br />.>
<br />pz
<br />1
<br />21
<br />. £
<br /><
<br />DEATH (Ma., Day, Yr.)
<br />233 a � to .
<br />�z=
<br />=, -,.
<br />3
<br />e,,,, a
<br />LIZ
<br />DATE SIGNED (Mo. Doy, Yr.)
<br />24o.
<br />HOUR OF DEATH
<br />24b. M
<br />DATE SIGNED (Mo., Day, Yr.)
<br />L,�
<br />I[ c
<br />23b. , ` -
<br />l ,v a$ `SQ
<br />HOUR OF DEATH
<br />y ` ^T
<br />23c. O L '. V M
<br />PRONOUNCED DEAD
<br />(Mo., Doy, Yr.)
<br />24c. •
<br />PRONOUNCED DEAD (Hour)
<br />24d. M
<br />Ti the b.t of my k..otedge, 4 at the new dam and p and due to the E O On Me basis of eaominotion and /or invest paKon, in my opinion deoM occurred at
<br />• v t time, date and place and due to e tour(.) stated
<br />t ...(.I .1.0.1 ` \
<br />23d,(Lpearon and Ddel a va ^a ^. c et t\`' . ,. .. . „ O S the M
<br />24. (Signature and Tide)
<br />J C
<br />Z
<br />0
<br />w
<br />N
<br />U
<br />TYPE OR PRINT IN
<br />PERMANENT INK
<br />SEE INSTRUCTION
<br />MANUAL
<br />Place
<br />NSC"
<br />Work.
<br />UC
<br />Reject
<br />A_
<br />B
<br />Port II
<br />TMV
<br />Census Tract No
<br />BVS-2 020-M- 00612.82
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />r Tom
<br />25 cH� A+JtJLL�h
<br />REGISTRAR
<br />26o. (Signature) B►
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c))
<br />k
<br />► ( a) & X 1.Zr &;a tt.--L
<br />(b)
<br />(c
<br />WOW INJURY AT WO
<br />(Speedy Yes or NM
<br />30e.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, 01 AS A CONSEQUENCE OF:
<br />PART OTHER SIGNIPKANT CONDITIONS- Conditions contributing a death but not related
<br />It
<br />ACCIDENT, SUICIDE. HOMICIDE. UNDET.,
<br />OR PENDING INVESTIGATION. (Specify)
<br />30o.
<br />o.
<br />DATE Of INJURY (M, Day, Yr.)
<br />30b.
<br />HOUR Of INJURY
<br />30c.
<br />PLACE OF INJURY- At beam, fern, great, factory,
<br />MM.. building, Mc. (Specify)
<br />30f.
<br />30g.
<br />DATE RECEIVED BY REGI
<br />26b.
<br />PART III. If FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes ❑ No
<br />DISC RIBE?WW INJURY OCCURRED
<br />30d.
<br />AUTOPSY
<br />(Specify Yes or C
<br />28 .
<br />LOCATION STREET OR LCD. H.
<br />STRAR (Mo., Doy, Yr.)
<br />Interval between onset and death
<br />Interval between onset and death
<br />Interval between onset and deoM
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Specify Ye. in No)
<br />29.
<br />CITY OR TOWN STATE
<br />NI
<br />Of e.
<br />
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