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<br />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 DEPARTAL*NT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL` DEPOSITORY,,,,FOR
<br />1
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />STANLti, S,, COOPER. H RECTOR
<br />MAR 31988 _ :. .
<br />LINCOLN, NEBRASKA BUREAU OF,V -ITAY. STATISTICS
<br />I
<br />900003520
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH",
<br />G
<br />a
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />Richard Leroy Johnson
<br />SEX v
<br />Male
<br />DATE Of DEATH (Mo., Day, Yr.)
<br />3 February 24, 1988
<br />1.
<br />RACE -(..g. White, Slack, Am.rican ORIGIN /DESCENT (e.g., Italian, Mexican, AGE -ta•r Birthday UNDER 1 YEAR UNDER 1 DAY DATE Of BIRTH (MO., Day, Yr.)
<br />Indian M. ee ify) G.rnw etc.) (Specify) O (Yrs.) 70 MOS. DAYS HOURS MINS. Aug. 2 , 1917
<br />American I6c.
<br />s. 60 6b 7.
<br />.,
<br />CITY AND STATE OF BIRTH (H nat,,, U.S.A., CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, NAME Of SPOUSE (If ril., give maiden nom.l
<br />nonM ountyl, WI ED,DIYOR ED(Specify)
<br />l�*='1n, Illinois `� U.S.A. IIDO°�arrI Ruth M. McBroom
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<br />B. 9. .
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done during most KIND OF BUSINESS OR INDUSTRY COUNTY OF DEATH
<br />Bell
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<br />�nstaller )4a.
<br />12 356-10-4079 13a 13b.
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION- Norse (If at in either, n HOSP OR INST. Indices• DOA,
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<br />FATHER - NAME FIR31 MIDDLE LAST MOTHER - MAIDEN NAME FIRST MIDDLE LAST
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<br />Charles - -- Johnson I Elizabeth Custer
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<br />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 DEPARTAL*NT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL` DEPOSITORY,,,,FOR
<br />1
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />STANLti, S,, COOPER. H RECTOR
<br />MAR 31988 _ :. .
<br />LINCOLN, NEBRASKA BUREAU OF,V -ITAY. STATISTICS
<br />I
<br />900003520
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH",
<br />G
<br />a
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />Richard Leroy Johnson
<br />SEX v
<br />Male
<br />DATE Of DEATH (Mo., Day, Yr.)
<br />3 February 24, 1988
<br />1.
<br />RACE -(..g. White, Slack, Am.rican ORIGIN /DESCENT (e.g., Italian, Mexican, AGE -ta•r Birthday UNDER 1 YEAR UNDER 1 DAY DATE Of BIRTH (MO., Day, Yr.)
<br />Indian M. ee ify) G.rnw etc.) (Specify) O (Yrs.) 70 MOS. DAYS HOURS MINS. Aug. 2 , 1917
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<br />s. 60 6b 7.
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<br />CITY AND STATE OF BIRTH (H nat,,, U.S.A., CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, NAME Of SPOUSE (If ril., give maiden nom.l
<br />nonM ountyl, WI ED,DIYOR ED(Specify)
<br />l�*='1n, Illinois `� U.S.A. IIDO°�arrI Ruth M. McBroom
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<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done during most KIND OF BUSINESS OR INDUSTRY COUNTY OF DEATH
<br />Bell
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<br />12 356-10-4079 13a 13b.
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<br />des fit. F"�INncis Medical Center
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<br />Grand Island 2607 W. 2nd St.
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<br />FATHER - NAME FIR31 MIDDLE LAST MOTHER - MAIDEN NAME FIRST MIDDLE LAST
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<br />Charles - -- Johnson I Elizabeth Custer
<br />16 f L7
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<br />WAS DECEASED EvRR IN U . --cU
<br />`y.''"Yesn:Il`jy_31 43and 3- X10 -46 ,9 Ruth M. Johnson_- Wife -2607 W. 2nd St. -Grand Is an NE.
<br />BURIAL, Cremation, Removal DQjeb . 26 1988 CEMETERY OR CREMATORY - NAME
<br />�10d ITY OR TOWN STATE
<br />20o.
<br />Burial 2T 2oT Westlawn Memorial Park Island, NE.
<br />A ER- SIGNATURE 6 LICENSE NO. I/ 3U FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />(- ry 7 �iApfel- Butler - Geddes 1123 W. 2nd, Grand Island, NE. 68801
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<br />REGISTRAR DATE RECEIVED c., aY.
<br />26b. MAR 1 1988
<br />26x. (Signot.r.) ►
<br />b. 27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUS PER LINE FOR . (a), (b), AND (c)) InNr -I ben een •.• and deerb
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<br />(b) �� "� "' t 1 re.val be - 1.0o•et and death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />PART THER SIGNIfKANT CONDITIONS- Cendiriorr• cenMbetiwg a dwrb b.t net -land DREG III. IF THE ►AST 7THERE THST (SUp«ily ►e• « Nel EXAMINER OR CRORON! AL
<br />(Specify YNe)
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<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., DATE Of INJURY (Me., Der, Yr.) HOUR Of INJURY DESCRIBE HOW INJURY OCCURRED
<br />OR ►ENDING INVESTIGATION. (Specify)
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<br />REGISTRAR DATE RECEIVED c., aY.
<br />26b. MAR 1 1988
<br />26x. (Signot.r.) ►
<br />b. 27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUS PER LINE FOR . (a), (b), AND (c)) InNr -I ben een •.• and deerb
<br />PART r C- .�
<br />(e) w interval berwen onset and d-1%
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