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<br />STATE OF NEBRASKA
<br />WHEN ! THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/14/2016
<br />LINCOLN, NEBRASKA
<br />30o.
<br />INJURY AT WORT
<br />(Specify Y.. No)
<br />30e
<br />DECEDENT- N
<br />FIRST MIDDLE LAST
<br />LeRoy Venn Pa 4t ,an
<br />RACE- (..g., White, Bleck, American IORIGIN /DESCENT(e.g., Italian, M., can, I AGE -ton Birthday
<br />Y1
<br />CITY AND STATE OP 0IRTH (If not in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED,
<br />name caunrryj WIDOWED, DIVORCE° (Specify)
<br />UNDER 1 YEAR I UNDER 1 DAY ATE OF BIRTH (Mo., Doy, Er-)
<br />Indian. .tc (Sp.cify) German. Mc.) (Specify) r ; (Tn.) 6b
<br />MOS. ■ DAYS
<br />w to .. 5 Am2R.LCan 1 bo 56
<br />GA and i.at'and, Nebnasha 9. U.S.A. ,o " Maiutied 11.Ft;;neeis L. Doenring
<br />SOCIAL SECURITY NUMBER USUAL OCCUPAT ON (Give kind of work don, during most KIND OF BUSINESS OR INDUSTRY COUNTY OF DEATH
<br />S05-22-7605 n Jp�y of working life, even i /ntir.d)
<br />70
<br />12.:5 - 7605 1,0. SupeAkntenden t 13b.. Con.stkuetion
<br />CITY, TOW OR tOCAT1ON OF DEATH INSIDE CITY LIMITS HOSPITAL ORoOTHE! INSTITUTION - Nome (1f not in .
<br />(Specify Yes or No) give street and number)
<br />b Sit( nd 'stand 14c. Yen 14d: Lutheran Ateman cast Hogs i#art 14.. Inpa ;i
<br />RESIDENCE -STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUM ER I NSIDE CITY LIMITS
<br />(apai:y Y.i ar htn)
<br />15.. V
<br />1s Nebnask.a I5b. Hatt
<br />16. John
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />iYet, no qr nk11 Of yet, give war and dates of service)
<br />18.
<br />B DATE Feb BURIAL, Cremation, Removal DAT . 26
<br />8u t .tz,,t I 20b. 1980
<br />25. W. J Lawt
<br />REGISTRAR
<br />1 ...
<br />(d
<br />ER - NAM FIRST
<br />LAVER - SIGNATURE & LICENSE
<br />r � NO. -J y_�c
<br />s`ih. beset .f my knowledge, death acckrrre8 •
<br />cewieh tested.
<br />230. (Siyhatare •and Tide) N L ,
<br />'DATE SIGNED ..M0., Dd.' Yr
<br />23b. 25 February 1980 23c.
<br />30f.
<br />1 306.
<br />6
<br />D ATE flf DEATH (Me.. Day. Yr.)
<br />23d, : 23 February 1980
<br />2
<br />15c
<br />201605302
<br />Grand I stand
<br />NAME AND: •ADDRES3>OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COL
<br />6a. (StanotomIPY
<br />DUE TO. OR AS A: CONSEQUENCE OF
<br />Diffuse metastaL.ic carcinoma of
<br />DUE 10, OR AS CONSEQUENCE OF:
<br />PART OTHER SIGNIFICANT CONUtTION5- Cendidona contributing to death but net related
<br />Ifs
<br />ACCIDENT, 5VICIDE, HOMICIDE, UNDET , I DATE OF INJURY (Mo., Day. Yr.)
<br />04 PENDING INVESTIGATION (Spect(y)
<br />PLACE OF INJURY- At Ammo, farm. stmt. factory.
<br />office building. etc (specify/
<br />27. IMMEDIATE CAUSE T (ENTER ONLY ONE CAUSE PER UNE FOR (o), (b)` AND (c))
<br />PART '
<br />(,, Acute respiratory failure
<br />STATE OF NEBRASKA -DEPARTMENT IOF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH D. ,-
<br />EX
<br />MIDDLE LAST .MOTHER- M.& IDEN NAME FIRST
<br />STANLEY COOPER
<br />ASSIST STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />DATE OF DEATH (Mo., Dar, Y
<br />2. Mate 3. Febitum 23. 1980
<br />HOURS MINS.
<br />6c.
<br />80
<br />7. Dec,L21
<br />NAME OF SPOUSE (If wife, give maiden name)
<br />14a
<br />Halt
<br />IF HOSP. OR INST; J dicate DOA,
<br />Outpatient /Ester. Rm., • Inpoh.nt (Sp.rify)
<br />MIDDLE
<br />F. Pawst.ian 17. Etta W. 1te.i
<br />INFORMANT - NAME - RELATIONSHIP- MAIUNG ADDRESS ISMS 02 LW,. C1t Riwti. STATE ;21Pj
<br />,04.3. Fnanee4 L. Pawstian -au a -1018 W. 5th -Grand I4.tand,
<br />L
<br />2D
<br />FUNERAL HOME - ' NAME AND. ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZD)
<br />CEMETERY OR CREMATORY --NAME LOCATION CITY OR TOWN' • STATE
<br />z Grand I stand' Cemetery 20.1. Grand I4tand, Nebnd4ha'
<br />. Ap{(e.t -Bu eA- Geddes 1123 W. 2nd, Grand ',stand, NE. 68801
<br />oft and plot. - d due to the On the boas of examination and /or investigation, in ^'y opinion death accunid of
<br />Z' the time. dote and place and de. to the cause(s) mated.
<br />24a. (Signature and Tine)
<br />R OF DEATH
<br />12:40
<br />PART 111. If FEMALE; WAS THERE A AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS? (Specify Y.. or No)
<br />Yes C Na D': 28 No
<br />j NODE OF iN' RY r855CRi8E HOW INJURY OCCURRED
<br />30e.
<br />M
<br />( TY ATTORNEY) (Type or Print)
<br />M
<br />LOCAT
<br />30g.
<br />30d.
<br />DATE SIGNED (Mo. Bay, Yr.)
<br />246.
<br />PRONOUNCED DEAD
<br />(Moe, Day, Yr.)
<br />24d
<br />HOUR OF DEATH
<br />24c.
<br />PRONOUNCED DEADI
<br />24.
<br />Grand I4.tand, NE. 68801
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />29.
<br />Interval b....A_ and d.uth
<br />Insliediate
<br />Intel-at set we+s .yn... end death ..
<br />_Two._ years
<br />Interval betr.eitsbas.f and death
<br />wAS CASE REFERRED TO MEDICAL
<br />EIUIMINER OR CORONER
<br />(Specify Yes or
<br />STREET OR R.F.D. No. CITY OR TOWN STATE
<br />
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