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<br />3. DATE OF Dak yeah
<br />Myron Ephran Oliver
<br />Male
<br />Febru 1996
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<br />Sa AGE Last Birthday I
<br />UNDER I YEAR
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<br />6 DATE — BIRTH Month. Dai yea,,
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF AW;UTH,.
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON PILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS WHICH IS THE LEGAL DEPOSITORY FOB
<br />VITAL RECORDS.
<br />L-r-E
<br />D E OF ISSUANCE -_
<br />BAR 6 1996 200105013 _ Sa/v Y s. COOPER ==
<br />assis�rAr - _tAREdsrltal
<br />LINCOLN, NEBRASKA NEBRASKA D OF HEAUK
<br />STATE OF NEBRASKA — DEPARTMENT OF HEATH " -_-
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF Dak yeah
<br />Myron Ephran Oliver
<br />Male
<br />Febru 1996
<br />4 CITY AND STATE OF BIRTH larotn USA. name co -Ily:
<br />Sa AGE Last Birthday I
<br />UNDER I YEAR
<br />UNDER ! DAY'
<br />6 DATE — BIRTH Month. Dai yea,,
<br />Shelton, Nebraska
<br />"r51 68
<br />August 14, 1927
<br />50 Mos DAY(
<br />5c HOURS MINI
<br />7 SOCIAL SECURTIY NUMBER
<br />2
<br />A
<br />HOSPITAL U Inpatient OTHER ❑ N s,ng Home
<br />/
<br />U d •� �LJ- -✓
<br />❑ ER Outpatient ❑ ;es den-
<br />Bb FACILITY - Name [# not msetuhon. give street and number/
<br />rn
<br />❑ DOA ❑
<br />25b DATE OF INJURY lMo Day.Yr/
<br />e, ,Spec,ry;
<br />Bc CITY TOWN OR LOCATION OF DEATH Id INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island Yes ® No ❑ Hall
<br />9a RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER /Inciudrg Zp Cdoe/ 9e INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 1918 N. Howard, 68801 ®
<br />10 RACE leg.. White. Black Amencan Indian
<br />t t ANCESTRY le q Italian. Mexican. German. etcl
<br />12 �-j MARRIED ❑ WIDOWED
<br />jJ
<br />73 NAME OF SPOUSE ll/ mie give magen name/
<br />M
<br />to
<br />N
<br />Evelyn E. Rauert
<br />14a USUAL OCCUPATION /Gve kind ol work done ounng mos
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Spec % only highest grade completed)
<br />i
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<br />Etta Brown
<br />18 WAS DECEASED
<br />EVER IN US ARMED FORCES' 02/08/1946—
<br />19a INFORMANT NAME -
<br />IYes no. a Ur* I
<br />I" yes gwe war and dales of services)
<br />- c
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<br />19b INFORMANT MAILING ADDRESS (STREET OR R D NO, CITY OR TOWN. STATE ZIP(
<br />1918 N. Howard, Grp--&f sl d, ebraska 68801
<br />EM ALMER- SIGNATURE B LICE NO
<br />28 February 1996
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 121E
<br />CEMETER, OR CREMATORY NAME
<br />,{`
<br />Q
<br />w
<br />c>.
<br />Westlawn Memorial Park Cemetery
<br />22a FUNERAL HOME NAME F
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funer o
<br />❑ °remanon ❑ Donation
<br />Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Grand Island, Nebraska, 68801 -5899
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<br />27d To the best d my knowledge death occurred at the time date and place and due to the
<br />28e On me basis of examination and or InvesT—on. !n my opni0n death occurred at
<br />°
<br />cause' stated
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<br />s� stated
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF AW;UTH,.
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON PILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS WHICH IS THE LEGAL DEPOSITORY FOB
<br />VITAL RECORDS.
<br />L-r-E
<br />D E OF ISSUANCE -_
<br />BAR 6 1996 200105013 _ Sa/v Y s. COOPER ==
<br />assis�rAr - _tAREdsrltal
<br />LINCOLN, NEBRASKA NEBRASKA D OF HEAUK
<br />STATE OF NEBRASKA — DEPARTMENT OF HEATH " -_-
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF Dak yeah
<br />Myron Ephran Oliver
<br />Male
<br />Febru 1996
<br />4 CITY AND STATE OF BIRTH larotn USA. name co -Ily:
<br />Sa AGE Last Birthday I
<br />UNDER I YEAR
<br />UNDER ! DAY'
<br />6 DATE — BIRTH Month. Dai yea,,
<br />Shelton, Nebraska
<br />"r51 68
<br />August 14, 1927
<br />50 Mos DAY(
<br />5c HOURS MINI
<br />7 SOCIAL SECURTIY NUMBER
<br />Sa PLACE OF DEATH —
<br />506-26-0493
<br />HOSPITAL U Inpatient OTHER ❑ N s,ng Home
<br />/
<br />U d •� �LJ- -✓
<br />❑ ER Outpatient ❑ ;es den-
<br />Bb FACILITY - Name [# not msetuhon. give street and number/
<br />St. Francis Memorial Health Center
<br />❑ DOA ❑
<br />25b DATE OF INJURY lMo Day.Yr/
<br />e, ,Spec,ry;
<br />Bc CITY TOWN OR LOCATION OF DEATH Id INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island Yes ® No ❑ Hall
<br />9a RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER /Inciudrg Zp Cdoe/ 9e INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 1918 N. Howard, 68801 ®
<br />Yes No ❑
<br />10 RACE leg.. White. Black Amencan Indian
<br />t t ANCESTRY le q Italian. Mexican. German. etcl
<br />12 �-j MARRIED ❑ WIDOWED
<br />jJ
<br />73 NAME OF SPOUSE ll/ mie give magen name/
<br />eta
<br />X'Whcan
<br />NEVER DIVORCED
<br />MARRI
<br />Evelyn E. Rauert
<br />14a USUAL OCCUPATION /Gve kind ol work done ounng mos
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Spec % only highest grade completed)
<br />i
<br />of wonum, /de, even it reared)
<br />Distribution Foreman
<br />Rainbo Bakery
<br />Elem Lary or Secomary (0 -12) College n n or S•!
<br />>;
<br />16 FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Chester Oliver
<br />1
<br />Etta Brown
<br />18 WAS DECEASED
<br />EVER IN US ARMED FORCES' 02/08/1946—
<br />19a INFORMANT NAME -
<br />IYes no. a Ur* I
<br />I" yes gwe war and dales of services)
<br />Yes
<br />I World War II 04/10/1947
<br />Evelyn E. Oliver
<br />19b INFORMANT MAILING ADDRESS (STREET OR R D NO, CITY OR TOWN. STATE ZIP(
<br />1918 N. Howard, Grp--&f sl d, ebraska 68801
<br />EM ALMER- SIGNATURE B LICE NO
<br />28 February 1996
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 121E
<br />CEMETER, OR CREMATORY NAME
<br />,{`
<br />I
<br />N Bonet ❑ Removal
<br />03/02/1996
<br />Westlawn Memorial Park Cemetery
<br />22a FUNERAL HOME NAME F
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes Funer o
<br />❑ °remanon ❑ Donation
<br />Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Grand Island, Nebraska, 68801 -5899
<br />___ _ _..___ ! imervai oelween onset ark? death
<br />PART ,f' yA A, � F v�� 1
<br />I
<br />tat
<br />DUE TO, ORj AS A C NSEOUENCE O
<br />4
<br />Interval between onset and death
<br />JJ
<br />Ibl ` L✓1 i'�'Y�'7
<br />�
<br />DUE TO. OR AS A CONSFOUENCE OF
<br />Interval between onset and death
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE WAS THERE A 124 AUTOPS`
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS' i
<br />EXAMINER OR CORONER'
<br />/
<br />U d •� �LJ- -✓
<br />(Ages 10 -54) Yes No Yes ti:
<br />Yes No
<br />26a
<br />25b DATE OF INJURY lMo Day.Yr/
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accidem ❑ Undetermined
<br />M
<br />P Suicide F-] Pendutq
<br />26e INJURY AT WORK
<br />26t PLACE OF INJURY - At home. farm. street facfay
<br />:k ACE
<br />26g LOCATION STREET OR R D rv0
<br />CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />yes No ❑
<br />Wild etc ISpeciNJ
<br />27a DATE OF DEATH /Mo Day Yr ,l
<br />28a DATE SIGNED /Mo Dak Yr l
<br />281) TIME OF DEATH
<br />-
<br />28 February 1996
<br />a
<br />>
<br />270 DATE SIGNED /MO Day yrl
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD ;Mo Day, Yr (
<br />2M PRONOUNCED DEAD lHom-
<br />g�
<br />28 February 1996
<br />:E
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<br />27d To the best d my knowledge death occurred at the time date and place and due to the
<br />28e On me basis of examination and or InvesT—on. !n my opni0n death occurred at
<br />°
<br />cause' stated
<br />_
<br />the time. date and place and due to the C _s
<br />s� stated
<br />/- �l
<br />j - &
<br />IS, nature and Title) I. fY M , r/
<br />ISM nature and Tidel P.
<br />29 DID TOBACCO USE CONTRIBUTE TO THr DEA 7
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED"'
<br />30 b WAS CONSENT GRANTED'
<br />❑ YES ❑ NO I�UNKNOWN
<br />❑ YES �NC
<br />❑ YES IZNO
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONER S PHYSICIAN OR COUNTY ATTORNEY; :Type or Pndr
<br />Dr. Ken Landin, 244.1 W. Faidley Ave., Grand Island, Nebraska 68803
<br />!J<D UAit rR.tU b't IHAH /MD Udy yr/
<br />zt4f uL X �, _ MAR 41996
<br />
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