|
C n
<br />I
<br />-
<br />TV
<br />= y .z _
<br />v
<br />CD rri
<br />M N CZD n Q -a o
<br />M N
<br />t� ? N -< G
<br />c� N p -r7 o H
<br />o
<br />CD
<br />. r,.. cc Z
<br />� O
<br />/
<br />v
<br />N
<br />WHEN TENS COPY CARRfES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN_ SERVICES
<br />SYSTEM, IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRB O"LE_WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTi;**M ft-ift616$
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE !r
<br />200005098 A c�oPCR
<br />hl AY 19 2" in, 0 ASSIOWIT Srd rE RE4sISiRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN -SERVICES -3
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICa FMANCE AND - SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />I L)F(.t DENT NAME FIRST MIDDLE LAST 2 SEX � � 3 DARE OF DEATH ,AI :,n 1ear
<br />Robert B. Gershom Male May 14, 2000
<br />j I CI' V AND STATE OF RIR 7 11 not i, US A. name Cdunfryl 1 5a AGE Last UNDER I YEAR UNDER 1 DAY 6. DATE OF BIRTH �M 0, 0,,, ,1r
<br />(Y I 5b MOS DAYS Sc HOURS MINS
<br />Grafton, Pennsylvania 67 March 30, 1933
<br />7 SOCIAL SECURTIV NUMBER Ba PLACE OF DEATH
<br />HOSPITAL. Inpalienl OTHER ❑ Nurs,nq Homo
<br />279 -28 -6423 - -
<br />gb FACILITY Name lllnof,nstifufion. give street and number) ❑ ER Outpatient ❑ Residence
<br />St. Francis Medical Center ❑ DOA ❑ Otherspeoh,
<br />8r rIT Y TOWN OR LOCATION OF DEATH I 8d INSIDE CITY LIMITS 1 8e COUNTY OF DEATH
<br />Grand Island Yes ® No ❑ Hall
<br />- - -- --
<br />9. RESIDENCE -STALE 79b COUNTY 9c GITV. TOWN OR LOCATION 9d STREET AND NUMBER /IncNding Zip Ccure TCIiy ,MI15
<br />Nebraska Hall Grand Island 1817 Garland St. 68803 - Yes [K] No ❑
<br />10 RACE leg_ Whne Blacx Amd,dan Intlian 11 ANCESTRY Ie g Italian. Mexican. German, eel 12 ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE e, le ... na,nel
<br />el, I'Specny) ISpecifyl NEVER DIVORCED White Scottish /Irish E] MARRIE Janis Jernigan
<br />Ida USUAL OCCUPATION ri;,ve endof work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecity only highest grade r. ompletedl
<br />of working Ide even it renrecli - - -i - - -
<br />Elemenlaryorsecondarylo -12I Collegr I a
<br />CMSGT Civil Eng. Manager USAF
<br />16 FATHER - NAME FIRST MIDDLE. LAST t MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />James Gershom Elizabeth Dynes
<br />I9 NA )t EASED V, :1 IN S ARMED FORCESn 119, ' NFORMANT - NAME
<br />Yn, ,iok )es y..,. war and pale. of se—d -I Ko r e a
<br />YES 9/4/52 8/31/78 - Vietnam) Steve Ingalls
<br />I9b INFORMANT MAILING ADDRESS STREET OR R F D NO CITY OR TOWN STATE. ZIP)
<br />15052 Sharp St. Omaha NE 68137
<br />?D E M - SIGNAIUR L E �- 21a METHOD OF DIS °OSITION 21b DATE 21, CFMETERV OR REMA. ) v NAME
<br />�� ,(`L ���� ®Banal ❑Remgvai 05/18/00 Bellevue Cemetery
<br />- -- - - - - Al-IFTAIERAL H M 21tl CEMETERY OR CREMATORY LOCATION „Iry J + rr)WN STATE
<br />Cremallon Donanon
<br />Bellevue Memorial aapel 0 ❑ Bellevue Nebraska - --
<br />22b rUNERAL HOME ADDRESS ISTREET OR R D NO CITY OR TOWN. STATE. ZIP)
<br />2202 Hancock St. Bellevue, NE 68005
<br />23 IMMEDIATE CAUSE 'ENTER ONLY ONE CAUSE PER LINE FOR gal Eh AND Let Intel 1.. between onset and I'll if,
<br />xPART
<br />NC1rL d .�•��/ k QNI Y 411 _
<br />aDUE TO. OR AS A CONSEQUENCE OF Inle,val between onset and beam
<br />PpP`P6 - - - -. -- -- --- ----- - - - - -- — -- --- - -- --- - - - - -_
<br />Dt,E r� Rn. ,.1 ).� :,FUUrNCFOF n,u :etw.r
<br />— �- - --
<br />)1HFR SIGNIFICANT CtiNDITIONS Cond.t onti rontnbuting 10 Ihn death out noI related PART III IF FEMALE WAS THERE A 2n AUTOPSY _T 2� JA'ASF REFF'7RFD iO MEDICAL
<br />PART PR ET NAIJCY IN TH _ AS1 _f MJNTN r KArTINFN OR I.CR JIVC 1'
<br />r Y
<br />Lit
<br />J ❑
<br />S1
<br />,, 10 541 Yes -I, Ves Nu -_ -Y" ❑ No
<br />26a 26b DA I OF INJURY MO Dav Yr) ' 26c HOUROFINJLJRY 26d DESCRIBE HOW IN.IURY I;RRED
<br />i
<br />—
<br />26e INJURY AT WORK 6; PLACE INJURY Al home a n tee, Rc ory 26q LOCATION STREET OR R F D NO "1P TOWN STAI=
<br />—_' Hire hu Id nq. etc /Spe iy) I
<br />�I 2 O ..,H Yes ❑ No ❑
<br />L')Alt F DEATH M, Dav Y,) 28a DATE SIGNED rW, Dav Yr1 �ZBb TIME OF DEATH
<br />M
<br />')A 7E SIGNED 'Mn Dav Yr 27c TIME OF DEATH i �' 28, PRONOUNCED DEAD HMO Day. Yrl 28d PRONOUNCE )DFAD /Hour
<br />T w
<br />a o a
<br />o C / / `J J / M U 28e On the basis of examination and or investigation,
<br />r 7vn I n1 esl O) my knpwledge ea dCCllrr P,d at t Ilme. Ie due IO the " ¢ n my op ( team --red al
<br />Xca sr ;1n.ed the time date and place and due to the causelsl stated
<br />S y,,11 e and I IF, ► __ IS, nature and Talel ► —
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATHS 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDI 30.b WAS CONSENT GRANTED'
<br />k YES ❑ NO ❑ UNKNOWN ❑ VES NO ❑ YES N()
<br />-
<br />r32aREGISTRAR E AND ADD �-061� RIP SIC N PHYSICIAN OR COUNTY ATTORNEVI (Type a Pnn(J
<br />I 32b DA E FILED BY REGISTRAR IMo Day Y,)
<br />Al I MAY 18 2000
<br />.1
<br />
|