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- - .- - -••.v Sony Hume a Residence U Other (Specify)
<br />8b. FACILITY - Name (If not institution.
<br />Good Samaritan
<br />Na . RESIDENCE STATE
<br />give street and number)
<br />Hospital
<br />9b. COUNTY
<br />Sc CITY, TOWN OR LOCATION OF DEATH
<br />Kearne y
<br />80 . INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />Yes
<br />Be. COUNTY OF DEATH
<br />Buffalo
<br />Nebraska
<br />1 RACE - (e.g, White. Black, American
<br />Hall
<br />Indian,
<br />II.
<br />9c. CITY. TOWN OR LOCATION
<br />Grand Island
<br />9d STREET AND NUMBER (Including
<br />2028 N. Howard
<br />Zip Code) 1 9e INSIDE CITY LIMITS
<br />(spoor Yes or " °'
<br />Yes
<br />White (Specify)
<br />YYl l ate
<br />14a. USUAL OCCUPATION (Glee kind work
<br />ANCESTRY (e g.,ltalian, Mexican, German, etc I
<br />(Specify)
<br />L; Cs•
<br />American
<br />12. MARRIED.NEVER MARRIED,
<br />WIDOWED. DIVORCED (Specify)
<br />Married
<br />13. NAME OF SP OUSE Of wi {e, give maiden name)
<br />Donna Dimmitt
<br />of done during most
<br />of working hie. even if retired)
<br />Foreman J
<br />16. FATHER - NAME FIRST
<br />14b. KIND OF BUSINESS INDUSTRY -
<br />:
<br />Construction Compan
<br />r5 FJiON (Specify only hldhest grade c t edl
<br />Elementary or r Secondary 10 -12) College (1 -4 1-4 or or 5
<br />8th
<br />MIDDLE - LAST
<br />Paul L. Rawlings
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />17. MOTHER . MAIDEN NAME I
<br />FIRST MIDDLE LAST
<br />Hazel C T Butter
<br />(Yes, no, or unk.)
<br />No
<br />20a. BURIAL, Cremallon,Removal,
<br />(If yes, give war
<br />and dates of services)
<br />20b. DATE
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO CITY OR TOW nIP)
<br />T IP)
<br />Donna Rawlings -2028 N. Howard -Grand Island, NE
<br />Donation
<br />Burial
<br />21. EMijACt�,R - SIG ATURE LICENSE
<br />July 2, 1990
<br />NO. rj
<br />20c. CEMETERY OR CREMATORY - NAME
<br />Grand Island Cemetery
<br />22. FUNERAL HOME • NAME AND ADDRESS (5
<br />.
<br />20tl. LOCATION CITY OR TOWN STATE
<br />Grand Island, Nebraska
<br />REET R
<br />0 / .3
<br />� �� G. v T
<br />7 SOCIAL SECURITY NUMBER
<br />23 IMMEDIATE CA
<br />PART
<br />11
<br />'6a. ACCIDENT. SUICIDE. HOMICIDE, UNDET,
<br />OR PENDING INVESTIGATION /Specify)
<br />'6e. INJURY AT WORK
<br />(Specify Yes or No)
<br />505 -36 -3469
<br />Ib)
<br />ICI
<br />201602.247
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE. -
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR'. /'
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUL 24 1990
<br />LINCOLN, NEBRASKA
<br />DUE TO, OR AS A CONSE
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />27a. DATE OF DEATH (MO.. Day, Yr/
<br />261. PLACE OF INJURY - At home, farm. street. factory,
<br />office building, etc. (Specify)
<br />June 28, 1990
<br />F 270. To the best of my knowledge, death
<br />cause(s) stated.
<br />IS d nature and Title)•
<br />:a DID TOBAE CONTRIBUTE T
<br />S ❑ NO
<br />'7
<br />❑ UNKNOWN
<br />8a. PLACE OF DEATH
<br />L
<br />260 DATE OF INJURY (Mo., Day. Yr)
<br />ed at the Mme, date
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART
<br />1 •
<br />E OF DEATH
<br />4:00 p.m,
<br />ace and due to the
<br />'1
<br />C YES
<br />NAME AND ADDRESS OF CERTIFIER ( PHYSICAN. CORONER'S PHYSICAN OR COUNTY ATTORNEY( (Type or Pont(
<br />M
<br />26g LOCATION
<br />STANLEY S. COOPER, DIREObR._
<br />BUREAU OF VITAL STATISTICS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH y
<br />1. DECEDENT - NAME FIRST
<br />MIDDLE LAST
<br />Robert - Lavern Rawlings
<br />4 CITY AND STATE OF BIRTH (If not in U S A., name country)
<br />Nebraska City, Nebraska
<br />he AGE - Last Birthday
<br />5 4
<br />UNDER 1 YEAR
<br />5b. MOS DAYS
<br />2 SEX
<br />Male
<br />11NDER 1 DAY
<br />5c. HOURS MINS.
<br />HOSPITAL: ,q Inpallent " ER Outpatient ❑ DOA
<br />R . F .D. NO ., CITY OR TOWN, STATE. ZIP)
<br />Apfel Butler 1 123 W. 2nd; Grand Isiand,NE.68801
<br />IE ER ONLY B CAUSE PER LINE FOR AND /
<br />Cat CC4( V -Zte h /A
<br />PART III IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes .. No O
<br />26c. HOUR OF INJURY 1 260. DESCRIBE HOW INJURY OCCURRED
<br />STREET OR R.F.D. NO
<br />28a DATE SIGNED (My.. Day Yr.)
<br />George Bascom M.D. 3320 Ave. A., Kearney, NE. 68847
<br />a. REGISTRAR
<br />June 28, 1990
<br />6 DATE OF BIRTH (Month. Day Year)
<br />Dec. 19, 1935
<br />24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />(Spy�:i4 Or No) EXAMINER OR CORONER?
<br />J /� I J s �J (Specify Yes or No)
<br />28c. PRONOUNCED DEAD (Mo.. Day'".Y).)
<br />DATE OF DEATH (Month. Day, Year)
<br />CITY OR TOWN STATE
<br />285. TIME OF DEATH
<br />Interval be een one and death
<br />9
<br />Interva between onset and death
<br />Interval between onset and death
<br />28d PRONOUNCED DEAD (Hour)
<br />M QZo
<br />° go
<br />8 28e. On the basis of e><ammabon and or inveshgabon, in my opinion death occurred at
<br />8 E , the time, date and place and due to the causelsl stated.
<br />[Snn ature and Title Ori
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 305 WAS CONSENT GRANTED?
<br />YES
<br />= NO
<br />M
<br />32b. DATE FILED BY REGISTRAR
<br />Mc V. •
<br />
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