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*TEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMMSER% SYSTEM R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL -_ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISMS- THE LEGAL DEPOSITORY FOR VITAL RECORDS _ DATE-R1419 CO 99 900002512=_ 904 ASS LINCOL�N, NEBRASKA HEALTHAND _ IrfEQ Bi STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE$ilJr�AID VITAL STATLSTICS CERTIFICATE OF DEATH 4- - -= 1 DECEDENT NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH Month. Day. Year) Joe 25, WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Lindy Bowden Male April 4, 1999 d. CITY AND STATE OF BIRTH (a not in U S.A.. name Country) Sa. AGE - Last Binnday I UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Alarm Day. Year) 5b. MOS I DAYS 5c: HOURS' MINS Doniphan, Nebraska (Yrs.l 71 May 25, 1927 7 SOCIAL SECURTIY NUMBER 88 . PLACE OF DEATH 126f. o6ice E O�i INJURY - A / . farm. street. factory o8ic bur a 506 -28 -8433 HOSPITAL ® Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (e not rnsklullon, give street and number/ St. Francis Medical Center ❑ DOA ❑ Other(specvtyi 8c. CITY TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yea ® No ❑ M Hall 9a. RESIDENCE - STATE 9b. COUNTY tic. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (InckOnglp 001883 2 tie. INSIDE CITY LIMITS Nebraska Hall Doniphan 421 W. Platte River Dr. Yea ❑ No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) t 2. [3 MARRIED ❑ WIDOWED t3. NAME OF SPOUSE (n wile. givemeiden name) etc.) ISDec,tyl White (Specify) American Li NEVER DIVORCED Mary Ann Denman tea USUAL OCCUPATION /Give kl d d wo k done titer g most 14D KIND OF BUSINESS INDUSTRY 32b. DATE FILED BY REGISTRAR (W... Ley yr.) APR 91999 15. EDUCATION (Swdfy D ay grade completed) of working tile, even it reined) Machinist Tool and Dye p Onda 10 -121 College 11.4 W 5.1 tt rraZfe 16. FATHER - NAME FIRST MIDDLE UST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME John NMN Bowden 79--111 Georgia NMN Harrell 18. WAS DECEASED EVER IN U.S. ARMED FORCES? - 4 6 9a. INFORMANT -NAME (Yns no or unk.) fit yes. give war and dates of services) Yes Korean Corxfilct 1 -29 -48 Mary Ann Bowden - 4 ?ifs 191b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIPI X421 W. Platte River Dr., Doniphan, Ne. 68832 X20 BALMER- SIGNATURE a�LICENSE NO. 21 a. METHOD OF DISPOSITION 21b, DATE 21c. CEMETERYORCREMATORY NAME RoaG,a elrt 43 ©Burial ❑Removal Aril 7, 1999 Cedarview Cemetery 122a. FUNERAL HOME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livid ston- Sondermann F.H. El Cremation El Donation Doniphan, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Ne. 68803 -4050 ca.�I mcu1A I c t,n n.,IM I CH UNLT Unit GAUSt YbH UNt FUH (a). Ibl. ANU IC)l I Interval between onset and deam .0 PART r. () ' 49- 13 a(� P 1.1 lr /1 �0 J I �/vd � X11 L) �G¢ a DUE TO. OR AS A CONSEOUENCE OF Interval between onset and deam Me DUE TO. OR AS A CONSEOUENCE OF _ _ _ 1•� rva- heb. n nnset and deem I 1 L. - c ., -:'- i_ 1 r l V tin n i t t OTHER SIGNIFI ANT ONDITIONS - Conditions contributing to the death but riot related PART PART PREGNANCY II n � III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? 1' ! y - (Ages 10 -54) Yes No Yes No Yes No 26a 26b. DATE OF INJURY (MO.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED F1Accident F-1 undetermined I- M Suicide ❑ Pend, nq HDmicde Investigation 26e. INJURY AT WORK Yes ❑ No ❑ 126f. o6ice E O�i INJURY - A / . farm. street. factory o8ic bur 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a DATE OF DEATH (A1o.. Day Yr) 28a DATE SIGNED (MO. Day. Yr.l 28b TIME OF DEATH E 8 !` ` > 1 M 277bb DATE SAjNED Alto Day/Yrl 27c. TIME OF DEATH LJ 28C PRONOUNCED DEAD (Ma.. Day Yd 28d. PRONOUNCED DEAD rNdud 270 To Ind best of tiny know fusels) stated. e 4ath occurred at the time, date and place and due to the 259. On the basis of examination and/or inveslgabon, in my opinion death occurred at the time, date and place and due to the causes) ataMd. 1 u 6 ISi nature and Title (Signature and Tine 29. DID TOBACCO USE CONTRIBUTE TO TH EATH9 30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? t/ YES ❑ NO ❑ UNKNOWN ❑ YES FX] NO �/ ❑ YES ❑ NO i1 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Piny ^1 6 rW IJ L-) . c !l 7 ( (g c-Z G ,XJ ZA L-i,� fJ e lD 32a REGISTRAR _� r 32b. DATE FILED BY REGISTRAR (W... Ley yr.) APR 91999 0' M