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Day, Yr.)
<br />r DECEDENT - NAME
<br />FIRST MIDDLE LAST I S
<br />SE% I DATE Of DEATH (Mo., D
<br />1 .
<br />ORIGIN/DESCENT (e. g., Italian, M.eican, A
<br />AGE -tort Birthday U
<br />UNDER 1 YEAR ,
<br />, UNDER 1 DAY D
<br />DATE OF BIRTH (Moe, D
<br />CITY AND STATE Of BIRTH (If net i
<br />in U.S.A., CITIZEN Of WHAT COUNTRY M
<br />MARRIED, NEVER MARRIED,
<br />NAME OF SPOUSE (If wile; give maiden name)
<br />8 C
<br />, N
<br />KIND OF BUSINESS OR INDUSTRY C
<br />COUNTY OF DEATH
<br />12. 508 -30 -8113 1
<br />INSIDE CITY LIMITS H
<br />HOSPITAL OR OTHER INSTITUTION- Nam. (If not to .tl6.r, I
<br />IF NOS. . OR INST. Indicate D
<br />146. G
<br />COUNTY C
<br />CITY, TOWN OR LOCATION S
<br />STREET AND NUMBER I
<br />E C
<br />1s.. N
<br />MOTHER - MAIDEN NAME FIRST M
<br />16 C
<br />1 (Yes no, or onki (If ye, .,or and dotes of service/
<br />_ ` 18. Yes I WWII 1/29/45- 7/10/46
<br />BURIAL, Cremation, Removal DATE
<br />DATE OF ISSUANCE
<br />JUL 1 - ; Nc
<br />LINCOLN, NEBRASKA
<br />e T N /
<br />� f' 3w
<br />DAT • DEATH (Mo., Day, Yr.)
<br />.i'
<br />23a.
<br />DATE SIG (Mo., Day, Yr.)
<br />23b. /_ `/ ' 7 ' "? ca
<br />26o. (Sig notar•)
<br />27. IMMEDIATE CAUSE
<br />(b)
<br />►. 30•. 30f.
<br />25 Duane Baker, M.D.
<br />"" REGISTRAR
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />20160113
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />HOUR OF DEATH
<br />` 4: ? i
<br />239. ( y
<br />IFICATE OF DEATH
<br />(ENTER ONLY;. NE CAUSE PER LINE FOR (a), (b), AND (c))
<br />M"P `RT C;"• e.cc�..G, -y�Zc
<br />la>
<br />DUE TO, O AS A CONSEQUENCE OF-
<br />30g.
<br />24a.
<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE ATRUE G_
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENfip OF, `` ,EATH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THF�.LEGAL DEPOSITORY FOR -
<br />VITAL RECORDS.
<br />STANLEY S. •COOPER, SIkECTOR
<br />BUREAU OF VITAL `STATISTICS
<br />19. Virginia Humiston (Wife) RR T1 Box 63B Island,Ne.
<br />CEMETERY OR CREMATORY - NAME
<br />3 1Q86 20..Westlawn Memorial Park 20d. Grand Island, Nebraska
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.f.D. NO.. CITY OR TOWN, STATE, ZIP) 68801
<br />22 . Livingston- Sondermann 505 West Koenig Grand Island, Ne.
<br />DATE SIGNED (Mo. Day, Yr.) HOUR OF DEATH
<br />24c
<br />To the bist of my knowledge, death occurred t the time, dote and plan end du 1 O • to the 0 0. .. bosh of renomination d /or . � ! .� inwatigoNan. in y opinion death occurred at
<br />• jEouce(.) .toted. the i.+e, dote and plat• and doe to the carrel.) elated
<br />" b. /C '-'i7;7- 24e. (Signatory and TiO.)
<br />i A {{yy . IA
<br />} NAME AND (S ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TYp• or Print)
<br />P.O. Box 2118 Grand Island, NE 68802
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />26b.
<br />1 let g_
<br />j PART OTHER SIGNIFICANT CONDITIONS -- Condition. contributing to death bw net nlot.d 1 PART
<br />REGNANCY IN THE FAST 3 MONTHS? Sp.< fy Ye. of Ne)
<br />i II
<br />■ Yes CJ: Not) 28.
<br />T ACCIDENT, SUICIDE, HOMICIDE, UNDET , DATE Of INJURY (Mo., Doy. Yr.' 1OOUR Of INJURY DESCRIBE NOW INJURY OCCURRED
<br />OR PENDING INVEST/GATION. (Specify) 1
<br />300. 1306. J30c,. M 30d.
<br />WONT INJURY AT WO PLACE OF INJURY -- At Memo, form, hnwt, factory, LOCATION
<br />(Spray Ye. on N. office building, etc. (Specify)
<br />24b.
<br />PRONOUNCED DEAD (Hour)
<br />JUL 10 1986
<br />29.
<br />M
<br />ltd. M
<br />Internal between onset and death
<br />Intornel between en..t and death
<br />InN.eol b•tweon *mot and doe*
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Specify Ye. or No)
<br />STREET OR R.F.D. No CITY OR TOWN STATE
<br />
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