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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE <br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE..A -TRUE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT. OF HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL-DEPOSITORY FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE , <br />APR k 1W STANLEY S. COOPER;. 'DIRECTOR <br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS <br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CEATIFICATE OF DEATH <br />200102164 <br />1 DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (MWnh. Day, Year) ' <br />Howard William Daffer Sr. <br />Male <br />February 5, 1992 <br />4 CITY AND STATE OF BIRTH (e not w U. S.A., name Cowrty) <br />5a.• AGE - Lam Binh W, <br />6. DATE OF BIRTH IM00t Day. Year) <br />MIS. DAYS <br />5c. HOURS! MiNS <br />tYrs -) 5b. <br />Lebanon, Nebraska <br />73 <br />Janua 23 1919 <br />7 SOCIAL SECURITY !UMBER !a <br />....,..�.:... �...;, <br />PLACE OF DEATH <br />❑ £R >.QwwMnf C7.40A <br />SOS -18 -0263 <br />... <br />OTHER. 4 NU13m9 Home '_ Resdance - n Oowr (SNMCNN! <br />eo FACILITY - Name (N 1W m wwn. give S"w am nUmoerr <br />Be, CITY, TOWN OR LOCATION OF DEATH <br />Be. INSIDE CITY LIMITS i ee COUNTY OF DEATH <br />(Specify Yes Or Nei <br />St. Francis Memorial Health Care <br />Grand Island <br />Yes I Hall <br />9a RESIDENCE - STATE <br />9b. COUNTY <br />9C. CITY. TOWN. OR LOCATION <br />9e STREET AND NUMBER (MCk4kV Zrp 17001 <br />Be . INSIDE CITY LIMITS <br />ISPOCWy Yes W No; <br />I <br />Nebraska <br />Hall <br />Grand Island <br />618 W. 10 S . <br />Yes <br />110 RACE - is g.. NMI. Black. Amsncan Ine1an. <br />11, ANCESTRY 1ic%.ft lan. Meaxarl. German. ak.) 12. MAFRRIED,NEVER MARRIED. <br />13. NAME OF SPOUSE to wee. give maMan name) <br />etc 1 (Specilyl <br />I <br />ISPOC41 WIDOWED. DIVORCED ( Specify( <br />White <br />American Married <br />L <br />toe. USUAL OCCUPATION lens kind or work done eumg moat 146. <br />KIND OF BUSINESS INDUSTRY <br />or working tea. even 0 rowed, ,✓ <br />ar <br />EWn@ft y w SftWx rY 10 -121 i Co1Nge 11.4 a S.) <br />Store Manager <br />Grocery i <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST <br />Harlow James Daffer <br />16 WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME - MAILING ADDRESS ISTREET OR R.F D. NO.. CRY OR TOWN, STATE, ZIP) <br />119. <br />(VOL no. or LOW) l0 va. Olva war and Cain of strmft <br />Yes: -45 Lorine Daffer -618 W. 10th St. -Grand Island, NE.6880] <br />12" BURIAL Crams I^RSrn0val <br />2% DATE <br />20c CEMETERY OR CREMATORY - NAME 20e. <br />LOCATION CITY OR TOWN STATE <br />Donawn <br />I <br />Burial <br />Feb. 8, 1992 <br />Westlawn Memorial Park <br />Grand Island NE. <br />21 E R - SIGNAT O. <br />22 FUNERAL HOME • NAME AND ADDRESS fSTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />90 <br />fel- Butler- Geddes 1123 W. 2nd Grand <br />one" 23. <br />Ir.ATE USE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (bj. AND tc)) Interval between onset ana etath <br />PART i <br />I S 1 Zi:4['!Li <br />DUE TO. OR AS A CONSEQUENCE OF Interval between onm and death <br />DUE TO. OR AS A CONSEQUENCE OF' I ime"al between Onset and dem <br />Ira <br />OTHER SIGNIFICANT CONDITIONS - Condl)ons COrIa'61" to dean bud not M4ftd <br />PART 111 IF FEMALE.. WAS THERE A <br />24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />i PART <br />PREGNANCY IN THE PAST 3 MONTHS' <br />lSpet+ty Yes w No/ <br />EXAMINER OR CORONER, <br />11 <br />Yes ❑ No �' <br />No <br />ISpe 4 Yea W NW <br />26a ACCIDENT, SUICIDE, HOMICM UNDET.. <br />126b. DATE OF INJURY 100 -Day. Yr:) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE NOW INJURY OCCURRED <br />OR PENDING INVESTIGATION (SpsC#y) <br />1_� <br />26e INJURY AT WORK <br />261. PLACE OF INJURY - At tW", farm- Sn*L ISC%XY. <br />28g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE <br />(SpecM Yes W No! <br />olke bt d*V, etc. N5vocNyl <br />27a. DATE OF DEATH M b . . D a y , Yr) <br />2U- DATE S I G N E D lab,. Day. Y I <br />M TIME OF DEATH <br />FEBRUARY 5, 1992 <br />1 <br />$ R. <br />a a <br />x <br />27b DATE SIGNED (ft., Day YO <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD /MO. Day Yr.1 <br />280. PRONOUNCED DEAD (Now) <br />€ <br />FEBRUARY 6, 1992 <br />9:30 a.m. <br />o <br />27e Tome bee d my k oe to late. and pace and due fg,(tre <br />29a On the bas15 of nam"nmon and w mva *n, m m <br />sOgat v OWnwn death oCCUrree at <br />CtuBNS{ ma/a0 �/1 <br />E <br />Ills hnw, daM O10 Piece am due to Ito cauemsi slated <br />( ra and TMeI► r ""'� <br />fSwwwe and Tft <br />29a DID TOBACCO USE CONTPJOYTO THE DEATHk 306 <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30b WAS CONSENT GRANTED' <br />X-S C O C UNKNOWN <br />p YES <br />:: YES <br />31 NAME 4fND ADDRESS OF TIFtER (PHYSICAN, CORONERS PHYSICAN OR COUNTY ATTORNEY) (Type W PmU) <br />J. V. R ss M.D. idle y, Grand Island, NE. 68803 <br />32a REGISTRAR <br />- • rwoc- . <br />32b DATE FILED BM (y �" �!!7/ <br />� <br />I <br />EXHIBIT "A" <br />