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9a. RESIDENCE - STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />9c CITY. TOWN OR LOCATION <br />Grand Island <br />90. STREET AND NUMBER Inc i d.rerg Zip Code) <br />816 S. Sycamore 68801 <br />9e INSIDE CITY LIMITS <br />Yes r7 No <br />10 RACE - (e.g.. White Black. American Indian. <br />etc. ISOecihl <br />White <br />l S <br />11 ANCESTRY le q_ Italian. Mexican. German eta <br />ISPecdyl <br />American <br />12 [�] MARRIED ii WIDOWED <br />: . <br />0 NEVER ❑ DIVORCED <br />MARRIED <br />13 NAME OF SPOUSE (If wile glee mar den name) <br />Mildred Chadwick <br />14a. USUAL OCCUPATION )Gee kind of work done dunng most <br />el working Ire. even it reeredf <br />Laborer <br />I <br />145 KIND OF BUSINESS INDUSTRY <br />Refinery Talcum Company <br />15 EDUCATION 'Spec ay only highest grade completed) <br />Eleme or Sect nary l0 -121 College i t -4 or S • i <br />Y <br />16. FATHER - NAME FIRST MIDDLE LAST <br />Harry Loveland <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Marie Van Valkenburg <br />18. WAS DECEASED EVER IN I,I ARMED FORCES' Korean <br />• <br />Yes: I 16 - 2 9 1 950 dale 6 - 1 � - 5 19 56 <br />Y Y e s <br />19a. INFORMANT - NAME <br />Mildred A. Loveland <br />196 INFORMANT MAILING ADDRESS (STREET OR R.F D NO CITY OR TOWN. STATE. ZIPI <br />816 S. Sycamore, Grand Island, Nebraska 68801 <br />20. EMBA A - SIGNATURE 10ENS N <br />. <br />• #1212 <br />21a. METHOD OF DISPOSITION <br />E Burial El Removal <br />C Cremalew El Donato, <br />21b. DATE <br />Oct. 20, 1995' <br />21c CEMETERY OR CREMATORY NAME <br />Cemetery <br />Westlawn Memorial Park <br />22a. NERAL HOME - N E <br />Apfel- Butler - Geddes F.H. <br />210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP) <br />1123 W. 2nd Street, Grand Island, Nebraska- 68801 <br />OTHER SIGNIFICANT CONDITIONS - COnd4lons ContributIrlg to the death but not related <br />PART <br />II <br />PART III IF FEMALE WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />Ages 10 -54) Yes 7 No n <br />24 A�ITOPS <br />Yes es l l 4_ <br />25 WAS CASE REFERRED TO MEDICAL <br />ErifMINER OR CORONER"T <br />Yes I I No <br />26a <br />■ Accident ■ Undetermined <br />El Suede Ei Pending <br />Cil Hommcnle Investigation <br />260. DATE OF INJURY /Mo.. Day. Yr) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes No <br />26f. PLA AE EulOFrIN INJURY - hoe*. farm. street. factory <br />2159. LOCATION STREET OR R F _T v0. Cry OR TOWN STATE <br />27a DATE OF DEATH (Ma.. Day Yr.) <br />October 17, 1995 <br />To be Completed by <br />CORONER S PHYSICIAN <br />at COUNTY ATTORNEY <br />L-- ONLY <br />28a DATE SIGNED (Mo.. Day. Yr) 128b TIME OF DEATH <br />Y ,T` 1 275 DATE SIGNED (MO. Day Yr) <br />tip <br />e October 18 1995 <br />El <br />127c TIME OF DEATH <br />4:30 AM M <br />28c PRONOUNCED DEAD (Mo.. Day, Yr: `280. PRONOUNCED DEAD (Hour) <br />M <br />< , 270 To the best of my know • .ge. <br />CdU5e151 stated <br />� 'Signawre and Title) , <br />death .. tined at . d an0 Place <br />I I / I <br />& ( itil <br />and due to the <br />0._....----.)- <br />28e On the basis of examination and or Invesreaoon, rn my opinion dears occurred at <br />the time date and place and due to the Ta s nsl, staled <br />, )Signature and Title) ik <br />29 DID TOBACCO USE CONTRIB E Tv THE DEATH, <br />❑ YES h N• ❑ UNKNOWN <br />30 <br />.7 ...--- <br />I HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED <br />❑ YES I \/ HO <br />30b yyrS CCOcSENT GRANTED' <br />,,,I El YES I Tt{ NO <br />"`YYf"" <br />31 NAME AND ADDRESS OF - TIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, Time or Print( <br />Dr. John A. Wa oner Jr., 800 Alpha, Grand Island, Nebraska 68801 <br />32a REGISTRAR <br />ide <br />32b DATE FILED BT ?� 1ST AAR (Ma. Day Yr) <br />OCT 2 41995 <br />DATE OF ISSUANCE <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF-HLALT11 <br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THELEGAL DEPOSITORY FOR T <br />VITAL RECORDS. _ <br />I <br />1 <br />OCT 2 5 1995 <br />LINCOLN, NEBRASKA <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />Eugene Joseph Loveland <br />4. CITY AND STATE OF BIRTH )M not in US. A.. name country) <br />Estherville, Iowa <br />7 SOCIAL SECURTIY NUMBER <br />485 -30 -8313 <br />Sa. AGE - Last Birthday <br />(Yrs I <br />64 <br />UNDER 1 YEAR <br />5b MOS. DAYS <br />8a. PLACE OF DEATH <br />HOSPITAL <br />2 SEX <br />Male <br />3 <br />UNDER 1 DAY <br />55. HOURS MINS <br />Inpatient OTHER <br />3 86. FACILITY - Name (M not rnstayoon. give street and number) <br />St. Francis Medical Center <br />8c CITY TOWN OR LOCATION OF DEATH <br />23. (MME E AUSE <br />0/5' <br />lal <br />PART <br />a <br />I <br />I <br />j Ibl <br />Grand Island <br />(cl <br />DUE TO. OR AS A CONSEQUENCE OF <br />DUE TO. OF AS A CONSEQUENCE OF <br />201702 <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />Bo ,NSIDE CITY LIMITS Be COUNTY OF DEATH <br />Yes a j NO L I Hall <br />IE NTER ONLY ONE CAUSE PER LINE FOR lal. lb). AND (cp <br />STAN EY S. COOPER <br />ASSISTANT STATE REGISTRAR <br />NEBRASKA DEPARTMENT OF HEALTH <br />U ER Outpatient <br />Li D O A <br />DATE OF DEATH (Month Day. Year) <br />October 17, 1995 <br />6 DATE OF BIRTH (Month. Day Year) <br />August 11, 1931 <br />C Nursing Home <br />C Residence <br />0 Other (Specrlvi <br />Interval between onset and death <br />Interval between onset and death <br />Interval between onset and death. <br />