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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU A SERVICES
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE�3Rii`D�€1NITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISS�SE€1t9Nx8tL IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />1[S. jCOOPER=
<br />DEC 13 2000 200102474 ASSISTANTSTATEfFGJS7�IR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTE/ff
<br />i
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE O_F_D_EAT-TH— S—
<br />EX-
<br />NAME FIRST MIDDLE LAST T. SE% 3 DATE OF DEATH lMOnlh Day. Year,
<br />John Henry Bowers Male December 1 2000 _
<br />1 CITY AND STATE OF BIRTH Ot not in U SA. name courery) 5a AGE LaslBirthdayT UNDER I YEAR UNDER 1 DAY 6. DATE OF BIRTH ,Month. Dav Y-O
<br />Merrick County, Nebraska Yr5 86 S1, vi DAYS HOURS MINIS October 18, 1914
<br />r SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH
<br />506 09 7030 HOSPITAL ❑ Inpatient OTHER '� Nursing Home M
<br />3b FACILITY Name at not— Nution, give street and number/ ❑ ER Outpatient ❑ Residence
<br />Wedgewood Care Center
<br />F-1 DOA ❑ Other (Specnvi
<br />3c CITY TOWN OR LOCATION OF DEATH Ed INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />Grand Island Yes ® No U Hall
<br />3a. RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER llncluding Zt COdel 9i : NSIDE CITY I IMITS M
<br />Nebraska Hall Grand Island 1516 N. Kruse 68803 Yes FK] NO ❑ M
<br />10 RACE - leg., White. Black. American Indian 1 t. ANCESTRY in g.. Italian. Mexican. German. elci t 2 © MARRIED ❑ WIDOWED t 3 NAME OF SPOUSE p/ wife qr,e maiden Hamel �i
<br />etc., Soeatyl (Speddyl
<br />White American ❑ NEVER DIVORCED Marian Pedersen Cv
<br />MARRIED
<br />14a 'USUAL OCCUPATION (Give kindot work done during most 14b KIND OF BUSINESS INDUSTRY 16. EDUCATION (Specify only highest grade compleledl
<br />of working rite. even d rehredl Elementary or Secondary (0 12) College ' o
<br />Owner/ rator Commercial Refri eration 8th Grade
<br />16 FATHER NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Lawrence NMI Bowers _. Maw_ NMI Steinbeck a�C
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES WWII j 19a INFORMANT - NAME
<br />Yes no or unx.) (if yes. give war and dales of services WWI
<br />Yes 11 -22 -43 - 11 -21 -45 Marian Bowers j�
<br />-- — - -_ _Vt
<br />191, INFORMANT MAILING ADDRESS (STREET OR R n D NO CITY OR TOWN. STATE ZIP( -
<br />1516 N. Kruse Ave. Grand Island It Nebraska 68803
<br />20 EMB MER URE 8 LICENSE 0 f 21a METHOD OF DISPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME `
<br />/0 ❑ Bui.al ❑ Reinova 'Dec. 5 2000 Grand Island City Cemetery '
<br />22a. TRAL H E - AM 2lo CEMETERY OR CREMATORY LOCATION CITY OR TOWN ST A.TE
<br />K ine Funeral Home ❑ Crema " °n ❑ °nna" Grand Island, Nebraska d Ill✓✓✓
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE. ZIP)
<br />3213 W North Front Street, Grand Island, NphrAqka 68803
<br />IMMEDIATE CAUSE ` \yam 't— I TT E�y ONLY ONNE CCA E PER LIN R 1� '.b) . AND (cI+ Interval between o s "1 1-"1
<br />PART ��� G\ �. 1 1 V C U
<br />I
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<br />DUE TO, OR AS A CONSEQUENCE OF Inl •v between ousel and ° -ary
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset a 1 i
<br />I
<br />lcl
<br />QjHER SIGNIFICANT CONDITIONS - Cd1//MMLLOO s contribtfing to the tlea but not related PART III IF FEMALE WAS THERE A aA AUTOPSY WAS CASE REFERRED TO MEDICAL
<br />PART I J PREGNANCY IN THE PAST 3 MO NTHS> EXAMINER OR CORONER''
<br />11 Ages 10 -541 Yes No yes No Yes Noy Ll
<br />26a 26b DATE OF INJURY (MO.. Day. Yr.) 26. UR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />ElQ.c.denl a Undetermined M
<br />Sint -de Pending 26e INJURY) WORK 261 PLACElOF INJURY AI home farm street) factory '6y L CO TIA ON STREET OR R F D. NO !:ITy OR TOWN STATC
<br />oH�ce buadmg. etc /Specilyl
<br />HOmiCitle InVe5ligali0n V2S ❑ No ❑ '
<br />27a DATE OF DEATH (MO. Day Yr/ 28a DATE SIGNED (MO Day yr 1 28b TIME OF DEATH
<br />0 M-
<br />,n lib DATE SIGNED /Mo. Dar Yr.) jIt. TIME OF DEATH $ > ° 28c PRONOUNCED DEAD IMO. Day, Yrl 28d. PRONOUNCED DEAD (Hour,
<br />15 k o N a
<br />g4GI� �a 16S — �-o V� moo; -M
<br />& M �_ z
<br />211 To the best of my kno dge deal oc ed at the a ale and pia e t d due to the Q 21 On he basis of examination and or Investigation, m my opinion death occurred a1
<br />P causelsl stated w I , t ^e om°. date and place and Hue to the causelsl stated-
<br />,'Signature and Title; Do �' \ ^�✓ _ Sgnature and Title) 0,
<br />29` DID TOBACCO USE CONTRI E TO THE DEATH' 3QQ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' �Ob WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN ❑ YES C ❑ YES NU —
<br />j 31 NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, ,Type or Pun ---rill
<br />John J. Cannella ME1. 729 No QRster Ave.. Grand Island. Nebraska 68803
<br />321, DATE FILED BY REGISTRAR (Mo. Day. I ";
<br />DEC 11 ?nun
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU A SERVICES
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE�3Rii`D�€1NITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISS�SE€1t9Nx8tL IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />1[S. jCOOPER=
<br />DEC 13 2000 200102474 ASSISTANTSTATEfFGJS7�IR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTE/ff
<br />i
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE O_F_D_EAT-TH— S—
<br />EX-
<br />NAME FIRST MIDDLE LAST T. SE% 3 DATE OF DEATH lMOnlh Day. Year,
<br />John Henry Bowers Male December 1 2000 _
<br />1 CITY AND STATE OF BIRTH Ot not in U SA. name courery) 5a AGE LaslBirthdayT UNDER I YEAR UNDER 1 DAY 6. DATE OF BIRTH ,Month. Dav Y-O
<br />Merrick County, Nebraska Yr5 86 S1, vi DAYS HOURS MINIS October 18, 1914
<br />r SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH
<br />506 09 7030 HOSPITAL ❑ Inpatient OTHER '� Nursing Home M
<br />3b FACILITY Name at not— Nution, give street and number/ ❑ ER Outpatient ❑ Residence
<br />Wedgewood Care Center
<br />F-1 DOA ❑ Other (Specnvi
<br />3c CITY TOWN OR LOCATION OF DEATH Ed INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />Grand Island Yes ® No U Hall
<br />3a. RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER llncluding Zt COdel 9i : NSIDE CITY I IMITS M
<br />Nebraska Hall Grand Island 1516 N. Kruse 68803 Yes FK] NO ❑ M
<br />10 RACE - leg., White. Black. American Indian 1 t. ANCESTRY in g.. Italian. Mexican. German. elci t 2 © MARRIED ❑ WIDOWED t 3 NAME OF SPOUSE p/ wife qr,e maiden Hamel �i
<br />etc., Soeatyl (Speddyl
<br />White American ❑ NEVER DIVORCED Marian Pedersen Cv
<br />MARRIED
<br />14a 'USUAL OCCUPATION (Give kindot work done during most 14b KIND OF BUSINESS INDUSTRY 16. EDUCATION (Specify only highest grade compleledl
<br />of working rite. even d rehredl Elementary or Secondary (0 12) College ' o
<br />Owner/ rator Commercial Refri eration 8th Grade
<br />16 FATHER NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Lawrence NMI Bowers _. Maw_ NMI Steinbeck a�C
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES WWII j 19a INFORMANT - NAME
<br />Yes no or unx.) (if yes. give war and dales of services WWI
<br />Yes 11 -22 -43 - 11 -21 -45 Marian Bowers j�
<br />-- — - -_ _Vt
<br />191, INFORMANT MAILING ADDRESS (STREET OR R n D NO CITY OR TOWN. STATE ZIP( -
<br />1516 N. Kruse Ave. Grand Island It Nebraska 68803
<br />20 EMB MER URE 8 LICENSE 0 f 21a METHOD OF DISPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME `
<br />/0 ❑ Bui.al ❑ Reinova 'Dec. 5 2000 Grand Island City Cemetery '
<br />22a. TRAL H E - AM 2lo CEMETERY OR CREMATORY LOCATION CITY OR TOWN ST A.TE
<br />K ine Funeral Home ❑ Crema " °n ❑ °nna" Grand Island, Nebraska d Ill✓✓✓
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE. ZIP)
<br />3213 W North Front Street, Grand Island, NphrAqka 68803
<br />IMMEDIATE CAUSE ` \yam 't— I TT E�y ONLY ONNE CCA E PER LIN R 1� '.b) . AND (cI+ Interval between o s "1 1-"1
<br />PART ��� G\ �. 1 1 V C U
<br />I
<br />a
<br />DUE TO, OR AS A CONSEQUENCE OF Inl •v between ousel and ° -ary
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset a 1 i
<br />I
<br />lcl
<br />QjHER SIGNIFICANT CONDITIONS - Cd1//MMLLOO s contribtfing to the tlea but not related PART III IF FEMALE WAS THERE A aA AUTOPSY WAS CASE REFERRED TO MEDICAL
<br />PART I J PREGNANCY IN THE PAST 3 MO NTHS> EXAMINER OR CORONER''
<br />11 Ages 10 -541 Yes No yes No Yes Noy Ll
<br />26a 26b DATE OF INJURY (MO.. Day. Yr.) 26. UR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />ElQ.c.denl a Undetermined M
<br />Sint -de Pending 26e INJURY) WORK 261 PLACElOF INJURY AI home farm street) factory '6y L CO TIA ON STREET OR R F D. NO !:ITy OR TOWN STATC
<br />oH�ce buadmg. etc /Specilyl
<br />HOmiCitle InVe5ligali0n V2S ❑ No ❑ '
<br />27a DATE OF DEATH (MO. Day Yr/ 28a DATE SIGNED (MO Day yr 1 28b TIME OF DEATH
<br />0 M-
<br />,n lib DATE SIGNED /Mo. Dar Yr.) jIt. TIME OF DEATH $ > ° 28c PRONOUNCED DEAD IMO. Day, Yrl 28d. PRONOUNCED DEAD (Hour,
<br />15 k o N a
<br />g4GI� �a 16S — �-o V� moo; -M
<br />& M �_ z
<br />211 To the best of my kno dge deal oc ed at the a ale and pia e t d due to the Q 21 On he basis of examination and or Investigation, m my opinion death occurred a1
<br />P causelsl stated w I , t ^e om°. date and place and Hue to the causelsl stated-
<br />,'Signature and Title; Do �' \ ^�✓ _ Sgnature and Title) 0,
<br />29` DID TOBACCO USE CONTRI E TO THE DEATH' 3QQ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' �Ob WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN ❑ YES C ❑ YES NU —
<br />j 31 NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, ,Type or Pun ---rill
<br />John J. Cannella ME1. 729 No QRster Ave.. Grand Island. Nebraska 68803
<br />321, DATE FILED BY REGISTRAR (Mo. Day. I ";
<br />DEC 11 ?nun
<br />
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