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<br />Sa AGE - Last 1111 I
<br />UNDER t YEAR
<br />-So
<br />UNDER 1 DAY
<br />- - __
<br />6 DATE OF SIFT H /Month. Dat 1' +,art
<br />Cairo - , Nebraska
<br />— - -- -- - --
<br />—
<br />Y,
<br />-- - - - - -- 87
<br />1� C r
<br />5c HOURS MINIS S
<br />I April 21, 1913
<br />T
<br />D
<br />506-18-5378
<br />HOSPITAL ❑ ,epanent OTHER Nurs,nq Home
<br />-
<br />ER Outpatient
<br />❑ p ❑ Residence
<br />Bb FACILITY -Name (If nqf msfilUlipn. give street and number)
<br />9 I
<br />Beverly Health Care
<br />At Lakeview
<br />❑ DOA ❑ Other lSpeolyt
<br />11 CITY TOWN OR LOCATION OF DEATH
<br />` p
<br />M
<br />N
<br />Yes [A Np ❑1
<br />Hall
<br />-7E3
<br />C D
<br />M
<br />9a RESIDENCE STATE
<br />91, COUNTY
<br />9c CITY TOWN OR LOCATION 9d STREET AND NUMBER IloGuding Zip Code) 9e INSIDE CITY LIMITS
<br />NE
<br />rn
<br />--.0
<br />O
<br />N � V
<br />le q Italian. Mexican. German. efel 17{'1 MARRIED ® WIDOWED 13 NAME OF SPOUSE II/ wr /e. give maiden Hamer
<br />�-J
<br />etc �SoeoNi y, (Specify)
<br />Whiten
<br />_.
<br />Amerizan - D1vOHOLD
<br />❑ MARRIE
<br />14d 'USUAL OCCUPATION (Give kind Of work done during most
<br />nl workmq rile even d rehredl
<br />c3
<br />-q
<br />N
<br />co
<br />c> -T1
<br />-n
<br />_ Farmer
<br />Agriculture
<br />16 FATHER NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />o
<br />o
<br />Stange
<br />7
<br />:= M
<br />IB WAS DECEASED EVER IN US ARMED FORCES'
<br />1-�9a INFORMANT NAME -
<br />'Ye? If yes give a! and dales of — vices)
<br />no n%a
<br />Barry Stange_
<br />M S
<br />LZ
<br />D W
<br />Cairo, NE 68824
<br />20 EMBALMER SIGNATlIREB LICENSE NO
<br />71a METHOD OF DISPOSITION '. 21b DATE CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑Burial ❑R.e.-. 10/1 /2000 �ent.NE .Crem.Ser.
<br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME - NAME
<br />Apfel Funeral Home
<br />❑ Cremal,on ❑Donat'or Gibbon, NE
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO
<br />O
<br />411 W 11th Wood River
<br />NE 68883
<br />23 IMMEDIATE CAUSE
<br />PART
<br />.ENTER ONLY ONE CAUSE PER LINE FOR a, 'b, AND IcL Interval between onset a^1 i -Tr
<br />a,
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />lml4val between onset and ream
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />,cj
<br />Int betwaen dose, nrni neam
<br />PA THER CNIFGA�rTIOf - C� ns cord, uting
<br />(`1�l_ `1
<br />to Ile tleath hut�lated PART III ,F FEMALE WAS THERE A
<br />PREGNANCY IN THE °AST 3 MONTHS'
<br />124 AUTOPSY
<br />25. WAS CASE REFERRED IO MEDICAL
<br />E %AMINEG OR CORON`r
<br />C-n
<br />CA
<br />WHEN THIS COPYCARR/ES THE RAISEQ S --
<br />SYSTW !P y
<br />THE AAEFS SKA I0Kt AND N SERVICES SYSTEM, VITAL STATISTV8 _ _IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS ,} -
<br />DATE OF ISSUANCE
<br />OCT 5 2000
<br />LINCOLN, NEBRASKA l Q HEALTH AND fSTANT ATEREGiSII�R
<br />h1UlAA_ S�'TEA€
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S664M FIX &q6 IDJOPPORT
<br />VITAL STATISTICS _-
<br />_____ CERTIFICATE OF DEATH
<br />)F '=DENT -NAME FIRS' :n MIDDLE LAST 2 SEX - 3. DATE OF DEATH Mnnln
<br />Henry Allen R ale September 30 2
<br />< CITY ANC STATE OF BIRTH 111 not in USA name country)
<br />Sa AGE - Last 1111 I
<br />UNDER t YEAR
<br />-So
<br />UNDER 1 DAY
<br />- - __
<br />6 DATE OF SIFT H /Month. Dat 1' +,art
<br />Cairo - , Nebraska
<br />— - -- -- - --
<br />—
<br />Y,
<br />-- - - - - -- 87
<br />MOS DAYS
<br />5c HOURS MINIS S
<br />I April 21, 1913
<br />7. SDI; IAI. SECURIIV NUMBER
<br />—L -------- ..__..-
<br />8a PLACE OF DEATH
<br />506-18-5378
<br />HOSPITAL ❑ ,epanent OTHER Nurs,nq Home
<br />-
<br />ER Outpatient
<br />❑ p ❑ Residence
<br />Bb FACILITY -Name (If nqf msfilUlipn. give street and number)
<br />9 I
<br />Beverly Health Care
<br />At Lakeview
<br />❑ DOA ❑ Other lSpeolyt
<br />11 CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />de COUNTY OF DEATH --
<br />Grand Island
<br />Yes [A Np ❑1
<br />Hall
<br />9a RESIDENCE STATE
<br />91, COUNTY
<br />9c CITY TOWN OR LOCATION 9d STREET AND NUMBER IloGuding Zip Code) 9e INSIDE CITY LIMITS
<br />NE
<br />Hall
<br />Cairo 405 S. Said Yes ® Np ❑
<br />10 RACE le g.. White. Black American Indian 11. ANCESTRY
<br />le q Italian. Mexican. German. efel 17{'1 MARRIED ® WIDOWED 13 NAME OF SPOUSE II/ wr /e. give maiden Hamer
<br />�-J
<br />etc �SoeoNi y, (Specify)
<br />Whiten
<br />_.
<br />Amerizan - D1vOHOLD
<br />❑ MARRIE
<br />14d 'USUAL OCCUPATION (Give kind Of work done during most
<br />nl workmq rile even d rehredl
<br />14b KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade compleled)
<br />Elementary or Segondary (0 -12) College n 4
<br />12 0 "
<br />_ Farmer
<br />Agriculture
<br />16 FATHER NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Fred
<br />Stange
<br />Agnes Ericksen
<br />IB WAS DECEASED EVER IN US ARMED FORCES'
<br />1-�9a INFORMANT NAME -
<br />'Ye? If yes give a! and dales of — vices)
<br />no n%a
<br />Barry Stange_
<br />19h INFORMANT MAILING ADDRESS (STREET
<br />OR R F U NO CITY OR TOWN STATE. ZIP( ----------- _. —' --
<br />17541 W Airport Rd
<br />Cairo, NE 68824
<br />20 EMBALMER SIGNATlIREB LICENSE NO
<br />71a METHOD OF DISPOSITION '. 21b DATE CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑Burial ❑R.e.-. 10/1 /2000 �ent.NE .Crem.Ser.
<br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME - NAME
<br />Apfel Funeral Home
<br />❑ Cremal,on ❑Donat'or Gibbon, NE
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO
<br />CITY OR TOWN. STATE. ZIP) --
<br />411 W 11th Wood River
<br />NE 68883
<br />23 IMMEDIATE CAUSE
<br />PART
<br />.ENTER ONLY ONE CAUSE PER LINE FOR a, 'b, AND IcL Interval between onset a^1 i -Tr
<br />a,
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />lml4val between onset and ream
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />,cj
<br />Int betwaen dose, nrni neam
<br />PA THER CNIFGA�rTIOf - C� ns cord, uting
<br />(`1�l_ `1
<br />to Ile tleath hut�lated PART III ,F FEMALE WAS THERE A
<br />PREGNANCY IN THE °AST 3 MONTHS'
<br />124 AUTOPSY
<br />25. WAS CASE REFERRED IO MEDICAL
<br />E %AMINEG OR CORON`r
<br />_
<br />�- is --ar? pOtF �NJI /RY � SC qi o res No Yes No,
<br />261 26b DATE OF-INJURY rMo Day Yri�_ OCCURRED
<br />,;nnet n, nen M
<br />I �
<br />- - -- -- -
<br />,r. de P �nr. �y 26e INJURY AT WORK 261 PLACE OF INJURY At tome farm ;meet lactory ?hy LOCH 710N STREET OR R F D NO (11 v OR TOW ^i
<br />❑ ❑ nH ce budding. et, Specify)
<br />ur�.ed vast gatidn Yes No
<br />i
<br />27a DATE OF DEATH (MO Day. vr.J 28a ngTE SIGNED /MO Dav vrl 281, TIME OF DEATH
<br />-_
<br />Sept. p 3 0, 2 0 0 0
<br />N J 270 DATE SIGNED IMO Day yrI 21, TIME OF DEATH > G Y r28c PRONOUNCED DEAD IMO Day. vr) 28d. PRONOUNCED DEAD rHom
<br />A _
<br />1120A
<br />L— M
<br />r i 271, T,) h best of my nowledge death 0 rred al Ih Ume date ar
<br />Id
<br />place e the -'i ( 28e in the oasis of examination and or investigation, in my od ion death ccu,r to ar
<br />ca s, Is stated \ �\ a the •,me date and place and due to the causels) stated
<br />, gnawre and Tine) ► J \y_\ I S: Hawn and 1!tlel ►
<br />29 DID TOBACCO L1 11 I:ONTRIBUTE TO THE DEATH' T— - -- ---- - --' --
<br />30a HAS ORGAN OF TISSUE DONATION BEEN CONSIDERED' 30.h W45 CONSENT GRANTED
<br />TES ❑ NO ❑ UNKNOWN ❑ YES -NG ❑ YES ^JO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY , t1,oe or PrY//YYYn -�nll --
<br />John J. Cannella ME( 729 N. Custer Ave Grand
<br />32a REGISTRAR 32b DATE FILED BY REGISTRAR ' Day "
<br />OCT 4 2000
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