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1 DECEDENT NAME <br />- FIRST MIDDLE LAST <br />Mark Franklin Brandon <br />4 CITY AND STATE OF BIRTH <br />r 2 SEX <br />Male <br />3. DATE OF DEATH ;Month Day. Year! <br />October 27, 1995 <br />(Ana( USA. name country! <br />Pryor, Oklahoma <br />7 SOCIAL SECURTIY NUMBER <br />5a AGE - Last Birthday <br />Yrs 37 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Monk. Day Year/ <br />July 1 1 1958 <br />55 MOS DAYS <br />5c. HOURS MINS <br />505 -90 -1622 <br />, <br />ea PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />El ER Outpatient ❑ Residence <br />❑ OOA ❑ Olhei /Spenty <br />80. FACILITY - Name /N not rnstmf+orr. 9,01 street and number) <br />St. Francis Medical Center <br />& CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />9a RESIDENCE - STATE <br />( 8d INSIDE CITY LIMITS <br />Yes [ No ❑f <br />6e COUNTY OF DEATH <br />Hall <br />Nebraska <br />10. RACE White. <br />98 COUNTY <br />Hall <br />9c CITY. TOWN OR LOCATION <br />Doniphan <br />96. STREET AND NUMBER (1/10 42mgZp Coder <br />P.O.Box 102 68832 <br />l 9e INSIDE CITY LIMITS <br />Yes) No ❑ <br />- leg, Black. American Indian. <br />ISpeo8y <br />I <br />14a USUAL OCCUPATION (G+ve kind of work done <br />of workmq/de, even (f refired( <br />11. ANCESTRY (e.g. Italian. <br />tS PecNA <br />American <br />during most <br />Mexican. German. etc1 <br />t 4b KIND OF BUSINESS INDUSTRY <br />12 7 MARRIED ❑ WIDOWED <br />.` <br />NEVER DIVORCED <br />❑ MARRIED 1 <br />15. EDUCATION <br />13 NAME OF SPOUSE pr vole give maiden <br />Susan E. Doering <br />ISpec,ty only highest grade completed) <br />Hama) <br />Production Worker <br />16. FATHER • NAME <br />Pump Manufacturing <br />Elements or Secondary 10121 College I1 -4 or S -t <br />le <br />FIRST MIDDLE LAST <br />Jimmy S. Brandon <br />18. WAS DECEASED EVER U.S. <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Ester Buie <br />(Yes no. or unk.) <br />No i <br />IN ARMED FORCES' <br />(8 yes. give war and dates of services) <br />Igor. INFORMANT - NAME <br />ci, .., c 1:2,,.,..,4,... <br />OTHER SIGNIFICANT CONDITIONS • Condnions contributing to the death but l <br />PART eat not related <br />11 <br />'6a <br />PART 111 IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS <br />(Ages 10 -54) Yes I f No ` ! I <br />24 AUTOPS/ <br />_ <br />Yes No — 1 <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />Yes <br />Accident ■ Undetermined <br />Swede ■ Pending <br />Homicitle Investgalron <br />i ❑ <br />26b. DATE OF INJURY (Mo.. Oay. 50) <br />26c. HOUR OF INJURY <br />M <br />No <br />264 DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />yes NO ❑ <br />261. PLACE OF INJURY - Al home, farm. street. factory <br />o ce buiMing, etc / SpecAy / <br />26g. LOCATION ' STREET OR R.F 0 NO. CITY OR TOWN STATE <br />WINO <br />NVOISAHd E.Pu'aiN <br />an n,un„n�an n I' <br />27a DATE OF DEATH (MO. Day. Yr( <br />A1yo <br />A3N13OII AkINDOD <br />NVIOISAHd $ H3NON0: <br />A0 Mald43 x9 01 <br />28a DATE SIGNED (Mo. Day 0 <br />28b TIME OF DEATH <br />M <br />275 DATE SIGNED /410 Day Yo) <br />/ <br />27c TIME OF DEATH <br />1 <br />2& PRONOUNCED DEAD (MD Day, yr! <br />28d. PRONOUNCED DEAD (Hour) <br />M <br />27d To the best of oc <br />my knowledge death cu _ rr lime. I and oue le the <br />0305el51 staled. <br />i <br />(Signature arid Title) 0. ,' - <br />28e On the basis of examination and 10 t Ca, lanon, m my opinion death occurred at <br />the time, dale and piece and due to e causelsl stated. <br />0. the (Signature and Tale) /A <br />S Lou ) 0BA000 USE CONTRIBUTE T6 HE DEATH, <br />-'Y'ES ❑ NO ❑ UNKNOWN <br />NAME <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED, <br />❑ YES El 740 <br />30.5 WAS CONSENT GRANTED' <br />❑ YES ❑ NO <br />1 AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY, , Tvnn ry Ponn <br />190 INFORMANT <br />bl <br />(cl <br />WHEN THIS COPY CARRIES THE RAISED. SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH, <br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON THE STATE <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSTTORY FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />NOV 2 7 1995 <br />LINCOLN, NEBRASKA <br />23. IMMEDIATE CAUSE <br />PART <br />(a) �. <br />Dr. Phillip Bu <br />2a REGISTRAR <br />MAILING ADDRESS <br />P.O.Box 102 Doni han Nebraska 68832 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO. /_ �/ <br />F RAL HOME- E <br />21a METHOD OF DISPOSITION <br />® Bunt ❑ Removal <br />❑ Cremation ❑ DonMron <br />21b. DATE <br />10/31/1995 <br />Cedar <br />Doniphan, Nebraska <br />Apfel- Butler- Geddes Funeral Haile <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO. CITY OR TOWN. STATE ZIP) <br />1123 West Second Grand Island 68801 -5899 <br />DUE TO, OR AS A CONSEOUENCE OF <br />DUE TO, OR AS A CONSEQUENCE OF <br />ket M.D. 3016 W. Faidley Ave., Grand Island, NE. 68803 <br />' 320 DATE FILED BY REGISTRAR /■0.. Day Yr) <br />STATE OF NEBRASKA DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF D <br />1STREET OR R,FD NC. CITY OR TOWN •STATE. ZIPI <br />(ENTER ONLY ONE CAUSE PER LINE FOR at (b). AND Ic(( <br />STANNEY S. COOPER <br />ASSISTANT STATE REGISTRAR <br />NEBRASKA DEPARTMENT OF HEALTH <br />216. CEMETERY OR CREMATORY LOCATION <br />201606.071 <br />21c. CEMETERY OR CREMATORY NAME <br />View Cemetery <br />CITY OR TOWN STATE <br />NOV 131995 <br />Interval between onset and death <br />Interval between onset and death <br />Interval between onset and death <br />