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<br />WHEN THIS COPYCARFuES THE RAISED SEAL OF THE NEBRASKA HEALTH �CES
<br />SYSTEM, W CERTAFES THE BELOW TO BE A TRUE COPY OF THE ORIGI Ef TH C�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST/#TSECTl01S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA TE OF ISSUANCE = i�'z�'t
<br />200101775 AIYLEYS.
<br />FEB 91999 as�sraHr��isT�iR
<br />LINCOLN, NEBRASKA HEALTH AND HUK4?j SE R SYVEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMM SEIEYICMVANCE-�SUPPORT
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE UST
<br />2, SEX
<br />M
<br />n
<br />n
<br />January 28, 1999
<br />4. CITY AND STATE OF BIRTH /snot in USA.. rims eounayl
<br />5a. AGE - Last Birthday
<br />- UNDER 1 YEAR
<br />UNDER I DAY
<br />8. DATE OF BIRTH (Monlih. Day. Yoarl
<br />sb. MOS I DAYS
<br />di
<br />C
<br />rn
<br />(Yrs.) 80
<br />June 29, 1918
<br />O
<br />Be. PLACE OF DEATH
<br />508 -01 -6677
<br />H OSPITAL: O Inpatiera OTHER: ❑ Nursing Home
<br />S
<br />A
<br />Z
<br />rt
<br />❑ DOA ❑ Other(Spacdyl
<br />>
<br />~
<br />c D
<br />©
<br />e=
<br />I Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (lncludr'ng Zip Cadet 9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Mall
<br />- - _- -
<br />-r1_2 _ : _ 1Bth_ s-e-.
<br />10. RACE -1 g- INhM1• . AlthadCall MOM.
<br />11. MCI )..
<br />12 A SNI '
<br />I & NAME OF SPOUSE /A' utiY. 9W men on mwt*
<br />.u.1(spxNl White
<br />�1 American /�J
<br />C.
<br />Reynolds "Sye" King _
<br />14a. USUAL OCCUPATION !Give kind of work dale dlaalg moll ('I j
<br />Nrebaldl i
<br />14b. KIND OF BUSINESS INDUSTRY (1 1,.
<br />7GV
<br />15, EDUCATION (Speciy only high" grade compNNd)
<br />E nu ar 10 -121 College It -4 or 5.1
<br />t�i trade
<br />of working ft am
<br />Homemaker
<br />Domestic
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alonzo Jefferson Cason
<br />AMY Josephine Smith
<br />0
<br />a _n
<br />C=>
<br />.....
<br />Jack R. Kin (Son) _
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 W. 10th St., Grand Island, Ne. 68801
<br />20. EM M - SIGNAT aLl NaE NO.
<br />� n
<br />21a. METHOD OF DISPOSITION:
<br />,,.
<br />CEMETERY OR CREMATORY NAME
<br />= M
<br />F-+
<br />Feb. 1, 1999
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOM AME
<br />d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑0reniadon ❑Ewalw
<br />M
<br />_0
<br />n CC)
<br />C)
<br />IK 1:1 YES NO
<br />31, NAME A �DR SS OF C;E:! MIER PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) /1.-,. • k / !'���
<br />(v\
<br />(` /Y1 -` ,,�y
<br />IREGIST�RAARR
<br />wDayy.
<br />305. EGISTRAR
<br />32b. DATE FILED BY III &. YY`rV./
<br />CD
<br />�
<br />__j
<br />a
<br />►-�
<br />c.
<br />o
<br />WHEN THIS COPYCARFuES THE RAISED SEAL OF THE NEBRASKA HEALTH �CES
<br />SYSTEM, W CERTAFES THE BELOW TO BE A TRUE COPY OF THE ORIGI Ef TH C�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST/#TSECTl01S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA TE OF ISSUANCE = i�'z�'t
<br />200101775 AIYLEYS.
<br />FEB 91999 as�sraHr��isT�iR
<br />LINCOLN, NEBRASKA HEALTH AND HUK4?j SE R SYVEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMM SEIEYICMVANCE-�SUPPORT
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE UST
<br />2, SEX
<br />3. DATE OF DEATH /Month. Day. YNrl
<br />Velma Jane King
<br />Female
<br />January 28, 1999
<br />4. CITY AND STATE OF BIRTH /snot in USA.. rims eounayl
<br />5a. AGE - Last Birthday
<br />- UNDER 1 YEAR
<br />UNDER I DAY
<br />8. DATE OF BIRTH (Monlih. Day. Yoarl
<br />sb. MOS I DAYS
<br />di
<br />5c. HOURS MINE.
<br />Broken Bow, Nebraska
<br />(Yrs.) 80
<br />June 29, 1918
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />508 -01 -6677
<br />H OSPITAL: O Inpatiera OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />t0. FACILITY - Name /Mnot inaearebrl. grvs sash and numW
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Spacdyl
<br />k. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I. Y« 13 No ❑
<br />I Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (lncludr'ng Zip Cadet 9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Mall
<br />- - _- -
<br />-r1_2 _ : _ 1Bth_ s-e-.
<br />10. RACE -1 g- INhM1• . AlthadCall MOM.
<br />11. MCI )..
<br />12 A SNI '
<br />I & NAME OF SPOUSE /A' utiY. 9W men on mwt*
<br />.u.1(spxNl White
<br />�1 American /�J
<br />11MARRIED NEVER DIVORCED
<br />Reynolds "Sye" King _
<br />14a. USUAL OCCUPATION !Give kind of work dale dlaalg moll ('I j
<br />Nrebaldl i
<br />14b. KIND OF BUSINESS INDUSTRY (1 1,.
<br />7GV
<br />15, EDUCATION (Speciy only high" grade compNNd)
<br />E nu ar 10 -121 College It -4 or 5.1
<br />t�i trade
<br />of working ft am
<br />Homemaker
<br />Domestic
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Alonzo Jefferson Cason
<br />AMY Josephine Smith
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />)Yes. no. or unk.) ff yes. grvn k'ar and dates of services)
<br />NO -- - - - - --
<br />Jack R. Kin (Son) _
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 W. 10th St., Grand Island, Ne. 68801
<br />20. EM M - SIGNAT aLl NaE NO.
<br />� n
<br />21a. METHOD OF DISPOSITION:
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />r
<br />©Bur.( ❑Renavai
<br />Feb. 1, 1999
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOM AME
<br />d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑0reniadon ❑Ewalw
<br />121
<br />Grand Island, Nebraska
<br />22b. 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 />2J. IMMtUTA I t I:AUbt �^ Itn i to VnL llnc unuac rcn uric rvn �a�. iul, nnv huh •w•.a. w•..w.. •n.w• .•+. •.
<br />PART
<br />I Interval between onset and n
<br />a DUE TO, rOR ^ ASIA
<br />CONSEQUENCE
<br />f• rnh 1 1' 1` f ) I
<br />DUE TO. Of, A C NSeOUENCE OF ., I Inlen,'t beto~_ onset and death
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Cord bons caltrbA% b the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />11
<br />IN THE PAST 3 MONTHS?
<br />..
<br />%AMINER OR CORONER'
<br />(Ages 10 -541 Yes No I
<br />Y., n No
<br />4- Yea No
<br />26a.
<br />26b DATE INJURY .. Day. YcJ
<br />28t, HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Untletermined
<br />M
<br />Suiatle Pending
<br />26e. INJURY AT WORK
<br />26L EEpp qqtt �'rrJJ�hgg farm' street. factory
<br />buildirip ek Y %S
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑ ❑
<br />oface rry)'
<br />Yes No
<br />27a. DATE OF DEATH /Mo.(`D'��ay.,YC/
<br />2Ba. DATE SIGNED (MO.. Day. Yr)
<br />28b TIME OF DEATH
<br />3
<br />1('-']1ff
<br />3si
<br />M
<br />27b, DATE SIGNED Day Ycl
<br />27c. TIME OF
<br />DEATH
<br />/'�
<br />29c. PRONOUNCED DEAD /MO.. Day, Yc)
<br />28d. PRONOUNCED DEAD /Noun
<br />� C �
<br />�((W....
<br />- 1 L
<br />( /►
<br />V M
<br />¢ i
<br />M
<br />270. Tome best d my k nth occurred a1 a aria ace aria tlue to the
<br />28e. On the Dania d examination and,or nveetipatton, b my opinion tlealh occurred at
<br />c sl sated.
<br />v a
<br />the time, date and place aria due to the cause(sl stated.
<br />(Si natur ntl TitleS
<br />nature and T*
<br />ass Zo. DID TOWAC SE CONTRIBUTE T TH DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN IDERED?
<br />30.b WAS CONSENT GRANTED?
<br />�- YES ❑ NO 1:1 UNKNOWN
<br />�� ❑ YES NO
<br />IK 1:1 YES NO
<br />31, NAME A �DR SS OF C;E:! MIER PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) /1.-,. • k / !'���
<br />(v\
<br />(` /Y1 -` ,,�y
<br />IREGIST�RAARR
<br />wDayy.
<br />305. EGISTRAR
<br />32b. DATE FILED BY III &. YY`rV./
<br />
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