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v A m n m z r M K 0 WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AN tOM SYSTE14 R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ORWCES fl THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/S jg THE LEGAL DEPOSITORY FOR VITAL RECORDS DAMPFISSUANCE JAN 112001 200103358 : CooPER ASS /S 1V1' LINCOLN, NEBRASKA $TATE REGIS R: HEALTH AND HUMMN SJEMAW SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERA FMk Cg: FpORT VITAL STATISTICS CERTIFICATE OF DEATH d CITY AND 0 N C:) CD F-' C3 W W Cn " ^'•" FIMJI MIDDLE Nebra } 1 19 RACE - Ie.g.. While. Black Amencan Ind,an 277vUiiS a 3 OATEOF DEATH iMnnt2 Dav vea�rfl 11. ANCESTRY 'e g Italian. Mexican German, etc) MARRIED �z 1LASt Johnson SUNDER etc l ISoeciy (Specflyl rn f 1 Ir, ! /�rWilliam rol�n O5Aaodate counlryl v n cn 14h KIND OF BUSINESSINOL)STRY 15 EDUCATION ISpecdy, only highest grade completed) IYrs I SL MOS rn C6 MINIS Arkansas FIRST MIDDLE MAIDEN SURNAME rn N Nannie Hair Jul 19 1918 URTIY NUMBER —L 8a PLACE OF DEATH !Yes. no o• unk.l Ili yes. grve war and dates of ser K:esl --4 M n 7C = CA HOSPITAL - Inpatient OTHER ❑ Nursing Home - Name Ill not ,nsti /upon. give street ane number! ❑ ER Outpatient ❑ Residence lizabeth Hospital I ❑ DOA ❑ Other 'Sper'ty AT DEATH Btl WgOE CITY LIMITS -- 8e COUNTY OF DEATH In �,..a. s Yes ry C N 1 ntw�e n w Q C7 I' ^�> co x n CD �-- ca cn all WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AN tOM SYSTE14 R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ORWCES fl THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/S jg THE LEGAL DEPOSITORY FOR VITAL RECORDS DAMPFISSUANCE JAN 112001 200103358 : CooPER ASS /S 1V1' LINCOLN, NEBRASKA $TATE REGIS R: HEALTH AND HUMMN SJEMAW SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERA FMk Cg: FpORT VITAL STATISTICS CERTIFICATE OF DEATH d CITY AND 0 N C:) CD F-' C3 W W Cn " ^'•" FIMJI MIDDLE Nebra } 1 19 RACE - Ie.g.. While. Black Amencan Ind,an 277vUiiS a 3 OATEOF DEATH iMnnt2 Dav vea�rfl 11. ANCESTRY 'e g Italian. Mexican German, etc) MARRIED �z 1LASt Johnson SUNDER etc l ISoeciy (Specflyl --EX L•UNDe December 000 FATE OF BIRTH ! /�rWilliam rol�n O5Aaodate counlryl a. AGE -Las eowlke 1 YEAR 1 DAY 8 OF BrMOnfh Day Year-1 14h KIND OF BUSINESSINOL)STRY 15 EDUCATION ISpecdy, only highest grade completed) IYrs I SL MOS DAYS 5c HOURS MINIS Arkansas FIRST MIDDLE MAIDEN SURNAME — Fowlkes Nannie Hair Jul 19 1918 URTIY NUMBER —L 8a PLACE OF DEATH !Yes. no o• unk.l Ili yes. grve war and dates of ser K:esl 4 -6053 HOSPITAL - Inpatient OTHER ❑ Nursing Home - Name Ill not ,nsti /upon. give street ane number! ❑ ER Outpatient ❑ Residence lizabeth Hospital I ❑ DOA ❑ Other 'Sper'ty AT DEATH Btl WgOE CITY LIMITS -- 8e COUNTY OF DEATH In �,..a. s Yes ry C N 1 ntw�e LZ C4 co .�-s. 0 Q d 9a RESIDENCE -STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER llncluding Zip coder 9e INSIDE CITV LIMITS Nebra } 1 19 RACE - Ie.g.. While. Black Amencan Ind,an Cairo_ 211 Stiiez 68824 Yes �] N. ❑ 11. ANCESTRY 'e g Italian. Mexican German, etc) MARRIED �z WIDOWED 13 NAME Hamel F SPOUSE if w,le o've maid Oen ❑ etc l ISoeciy (Specflyl j NEVER MARRIED DIVORCED I Ruth Brisbane ❑ Ida US UAL OCCUPATION rGlve kind of work done during most of working tile, even it retired) 14h KIND OF BUSINESSINOL)STRY 15 EDUCATION ISpecdy, only highest grade completed) Aviation Ele ✓ roar or SnCOndar 10 -12 Y� Y College 11 or S•i 16 FATH -NAME FIRST MIDDLE LAST I' "BOTHER FIRST MIDDLE MAIDEN SURNAME Robert Fowlkes Nannie Hair 16 WAS DECEASED EVER IN US. ARMED FORCES? - - "— ��x�7 T 19d INFORMANT .'SAME WWI — !Yes. no o• unk.l Ili yes. grve war and dates of ser K:esl `Yes 1 1942 -1`945 _Ruth Fowlkes 19b INFORMANT MAILING ADDRESS ISTREET OF R FO NO CITY OR TOWN. b. 11, 1 c ZIPI .. ----- - - - - -- Po Box 67 Cairo Nebraska 68824 20 E LMER- SIGNAT LICENSE NO 121 a. METHOD OF DISPOSI -Cr, T1b DATE 1211 CEMETERY ORCREMATORY NAME 1141 271 FUNERAL HOME - NAME Apfel Funeral Home 1 221 FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR 411 West 11th Po Box 126 Woos 23 IMMEDIATECAUSE PART I� I Ili Y� ✓ / ✓ / r/ DUE TO, OR AS A CONSEQUENCE OF LMpir;. DUE TO. OR AS A CONSEQUENCE OF I ®B Hal ❑ Re, ".,. 12 -28 -2000 1 Mt. Pleasant Cemetery _ 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑ Cremation ❑ D.,,a, Cairo, Nebraska STATE. ZIPI �— - - -- Nebraska 68883 CAUSE PER LINE FOR ai. lbl. AND (C)I cl PART OTHER SIGNIFICANT COONS - Conditions contributing 10 me death but not related PART fIi IF FEMALE. WAS THERE A 24 AUTOPSY PREGNANCY IN THE PAST 3 MONTHSv — Age, —10 -561 Yes No Yes No r 261 261. DATE OF INJURY /Mo Day Y 'Mil 6c HOUR OF INJURY Mil DESCRIBE HOW INJURY OCCURRED Interval /between onset and deal, v'1—v- Interval between once, and Beam Inl2rval between onset and deaf' WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER "' yes ❑ No IK i ^ /Accident Undetermined L _ /— �f `) C, 2- Suicide 11 Pending 6e. INJURY AT WORK 61 PLACE OF INJURY - At home farm sreef factory 9 LOCATION STREET OIl q; p. NO. GT I OR TOWN STATE ! ❑ 1 orrice bmld.hq etc / oecily) L L 11 Homicide investigation Ves No 170IDe /f� SJ2E(.` / J J / 27a. DATE OF DEATH lMo.. Day Yr) 28a. DATE SIGNED (MO. Day Yr./ 28b TIME OF DEATH U M 271 DATE SIGNEq Mo_ Day Yr) 271 TIME OF DEATH ! ¢ J 28c. PRONOUNCED DEAD tMo. Day. Yr) 28d. PRONOUNCED DEAD /Hour, 21 M 27d t e 5 I my knowledge alt*oCCUrred al the time date and ,lace a'tlue t �.7 _ ° 21 On the 11115 01 examm,bon and or investigation. in my comic, death occurred at CauselSl sled. the time. date and place and due to the cause(s) slated. (Sf nature and Tiael J. / ISi nature and Title) ► 29 DID TOBACCO SE CONTRIB J q 7 30.1 WAS CONSENT GRANTED I P- 30 a HAS ORGAN OR TISSUE A71ON BEEN CONSIDERED YES _.�NO ❑ UNKNOWN VES ❑ NO ❑ YES - NO 31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNFYI rTvoe w Print) David W. Voigt M.D. 555 So.-70 St. Burn Unit Lincoln, Nebraska 68510 321 REGISTRAR . 321. DATE FiLEO BY REGISTRAR„/Mb Day Y,J