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<br />WHEN THIS COPY CARRIES TT,E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEMACES
<br />SYSTEM, /T CERTFES ThE BELOW TO BE A TRUE COPY OF THE ORIGINA #WEILE*ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/9 ET- yok- ONCH_IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />200104456
<br />APR 51999 AS,yrsrATeREGI$iI#A
<br />LINCOLN, NEBRASKA HEALTH AND M1,MAN Sg"C@!_ SVST®_ 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE$VICfS �[A3 7riid i SL*_01
<br />VITAL STATISTICS
<br />CERTTFTCATR nF nF.ATH -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Moan. Day Yap)
<br />Marilyn Jean Hornby
<br />Female
<br />I March 11, 1999
<br />4. CITY AND STATE OF BIRTH (pnof h U.S.A. name county)
<br />Sa. AGE • Last Birthday I
<br />UNDER t YEAR
<br />rn
<br />S. DATE OF BIRTH /MIenM. Day. Ysarl
<br />MOS. l DAYS
<br />se. HOURS MINS.
<br />Hastings, Nebraska
<br />(Ural 66 5b.
<br />April 27, 1932
<br />�-'
<br />c> -t
<br />CD
<br />-,
<br />❑ ER OulpNlem ❑ Residence
<br />Bb. FACILITY •Name /p rat klssaillol, give akan and num0arl
<br />TV
<br />�
<br />TatAa
<br />I Be. COUNTY OF DEATH
<br />- i rn
<br />CD
<br />9a RESIDENCE - STATE
<br />c> r
<br />9c. CITY. TOWN OR LOCATION
<br />G
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />cam
<br />Grand Island
<br />2423 Del Monte Ave.
<br />O
<br />11. ANCESTRY le.g.. Callan. Mexican, German, etc)
<br />12. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /p wY71. Wt''a maiden namal
<br />etc.11SpacMl White
<br />(specify) American
<br />NEVER DIVORCED
<br />EIMARRIED
<br />Robert A. Hornb
<br />141. USUAL OCCUPATION /Give kkW d work done tieing map 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION fSpecity ony ra le compNlW(
<br />r*t
<br />-�
<br />D tz'
<br />C�
<br />_1%
<br />Jessie NMN Wailes
<br />Helen NMN Scudder
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES7
<br />19e INFORMANT - NAME
<br />(Yes. no. or unk.) IN yes. give war and dates of services)
<br />v
<br />�+
<br />Robert A. Hornb - Husband
<br />-
<br />cV
<br />�•'
<br />21 a. METHOD OF DISPOSITION
<br />21b DATE 21
<br />cn
<br />*)°
<br />©Bunal ❑Removal
<br />Mar. 16, 1999
<br />Grand Island City Cemeter
<br />22a. FUNERAL HOME • NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Cron1din ❑DeAation
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR fal. (b ween l. AND loll I Interval bet onset and death
<br />PART I
<br />�I I
<br />(a)
<br />DUE TO! AS A CONSEQUENCE OF 1 Imenal between Vel and death
<br />I
<br />IN I
<br />WHEN THIS COPY CARRIES TT,E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEMACES
<br />SYSTEM, /T CERTFES ThE BELOW TO BE A TRUE COPY OF THE ORIGINA #WEILE*ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/9 ET- yok- ONCH_IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />200104456
<br />APR 51999 AS,yrsrATeREGI$iI#A
<br />LINCOLN, NEBRASKA HEALTH AND M1,MAN Sg"C@!_ SVST®_ 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE$VICfS �[A3 7riid i SL*_01
<br />VITAL STATISTICS
<br />CERTTFTCATR nF nF.ATH -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Moan. Day Yap)
<br />Marilyn Jean Hornby
<br />Female
<br />I March 11, 1999
<br />4. CITY AND STATE OF BIRTH (pnof h U.S.A. name county)
<br />Sa. AGE • Last Birthday I
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />S. DATE OF BIRTH /MIenM. Day. Ysarl
<br />MOS. l DAYS
<br />se. HOURS MINS.
<br />Hastings, Nebraska
<br />(Ural 66 5b.
<br />April 27, 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />B.. PLACE OF DEATH
<br />506 -30 -4463
<br />HOSPITAL ® Iio- OTHER: ❑ Nursing Homo
<br />❑ ER OulpNlem ❑ Residence
<br />Bb. FACILITY •Name /p rat klssaillol, give akan and num0arl
<br />St. Francis Medical Center
<br />❑ DOA ❑ Dow j* awl
<br />BC. CITY. TOWN OR LOCATION OF DEATH 8d, INSIDE CITY LIMITS
<br />I Be. COUNTY OF DEATH
<br />Grand Island I. Yas © No ❑
<br />I Hall
<br />9a RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncAdYp Z06" 03
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2423 Del Monte Ave.
<br />Yes ® No ❑
<br />10. RACE • (e.g., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Callan. Mexican, German, etc)
<br />12. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /p wY71. Wt''a maiden namal
<br />etc.11SpacMl White
<br />(specify) American
<br />NEVER DIVORCED
<br />EIMARRIED
<br />Robert A. Hornb
<br />141. USUAL OCCUPATION /Give kkW d work done tieing map 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION fSpecity ony ra le compNlW(
<br />d working Alb,awnInkrsdl
<br />Sales Clerk
<br />Retail Furniture Sales
<br />E a 10.121 Cod"11 -4 or 5•I
<br />M Grade
<br />1S. FATHER - NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MKXXE MAIDEN SURNAME
<br />Jessie NMN Wailes
<br />Helen NMN Scudder
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES7
<br />19e INFORMANT - NAME
<br />(Yes. no. or unk.) IN yes. give war and dates of services)
<br />NO --- - - - - --
<br />Robert A. Hornb - Husband
<br />19b. INFORMANT ;RAILING ADDRESS ISTREET OR R.F.O. NO.. CITY OR TOWN. STATE. ZIP)
<br />2423 Del Monte Ave., Grand Island, Ne. 68803
<br />20. ALMER - SIGNATURE 6 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b DATE 21
<br />c. CEMETERY OR CREMAI JRV NAME
<br />R• O�eca- ..,c�.t 1l ¢3
<br />©Bunal ❑Removal
<br />Mar. 16, 1999
<br />Grand Island City Cemeter
<br />22a. FUNERAL HOME • NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Cron1din ❑DeAation
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR fal. (b ween l. AND loll I Interval bet onset and death
<br />PART I
<br />�I I
<br />(a)
<br />DUE TO! AS A CONSEQUENCE OF 1 Imenal between Vel and death
<br />I
<br />IN I
<br />DUE TO, OR AS A CONSEQUENCE OF . - - - 1 witai between onset and death
<br />1
<br />I
<br />(b)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions conoWuBrq to the death bet not related PART
<br />PART
<br />111 IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />11
<br />IN THE PAST 31 ONTHS?
<br />1 _ EXAMINER OR CORONER?
<br />(Ages
<br />10.54) Yes No
<br />o F]
<br />Yes No
<br />T Ves No
<br />26a
<br />26b. DATE OF INJURY /Ma. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />El SmcMe Pending
<br />26e. INJURY AT WORK
<br />26f. PPLAe E %IINNJ� V /A�home, farm. street. factory
<br />fR6 bullet 9 al'/
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ Homicide Investigation
<br />Yes[-] No ❑
<br />27a. DATE OF DEATH /Ado.. Day. Yr.)
<br />28a. DATE SIGNED /Red.. Day. Yr.l
<br />28b. TIME OF DEATH
<br />a<
<br />a
<br />M
<br />27b. DATE SIGNED /Ma. Day. Yr.l
<br />27c. TIME OF DEATH
<br />26c. PRONOUNCED DEAD (Ate.. Day, Yrl
<br />28d. PRONOUNCED DEAD /Hourl
<br />C
<br />i
<br />8
<br />10:5r4 M
<br />3
<br />M
<br />27d. To the best of my k . 6a a at ate Nine. and place and due a the
<br />26e. On the bash d examination and'ar Investigation, in my opinion death occurred et
<br />°
<br />A llrsMs) stated.
<br />b
<br />the time, dab and place and due to 8s causNtl slated.
<br />nahae and TNh
<br />and Title)`
<br />29. DID TOBACCO
<br />USE C TRIO THE TH7 i 30.8
<br />HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES 0 ❑- UNKNOWN
<br />.r ❑ YES NO
<br />❑ YES V NO
<br />31. NAME
<br />ANQftDDRESS OF ERTIFIER (PHYSICIAN, CORONER'S PIIV� OR EVI l7yp ar
<br />11 IN\
<br />321L REGISTRAR
<br />32b. DAYE FILED BY REGISTRAR (MO.. Day. Yr.)
<br />MAR 171999
<br />J, , - - - - IF
<br />AT= A V, WIM
<br />
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