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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF_- HEALTH,
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON AXE WITH THE -STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEG*L DEQOS?aR� FOR
<br />VITAL RECORDS. _ -
<br />DATE OF ISSUANCE`
<br />J` STAN E
<br />UN 2 41996 -S. COOPER
<br />ASSISTANT STATE REGIS16RAR
<br />LINCOLN, NEBRASKA NEBRASKA DEPARTMENT OF HEALTH
<br />STATE OF NEBRASKA - DEPARTMENT OFt1EALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />I DECEDENT NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day, Yee,/
<br />Marion Leroy Dean
<br />Male I
<br />June 16, 1996
<br />4. CITY AND STATE OF BIRTH - lil not m U.S.A., name countryl
<br />5a. AGE - Lest Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />e. DATE OF BIRTH /Month, Day, Y-1
<br />MOS. DAYS
<br />5c. HOURS MINIS
<br />;
<br />Ba and Nebraska
<br />lyre.) Sb.
<br />75
<br />October 25, 1920
<br />7, S(OCCIIAL SECURITY NUMBER Ile- PLACE OF DEATH
<br />_
<br />HOSPITAL. OTHER:
<br />Inpatient J Nursing Home
<br />_ -
<br />506- 14 -7276
<br />❑ ❑
<br />8b. FACILITY Name G7 not institution, give street and number/ ER Outpatient Resod- --
<br />St. Francis Medical Center ❑ DOA ❑ Othen /spadfvj -- _ --
<br />Be . CITY, TOWN OR LOCATION OF DEATH Bd. INSIDE -f" _•11 ""S Pe. COUNTY OF DEATH
<br />Grand Island Yes ® No ❑ I Hall
<br />9a. RESIDENCE - STATE
<br />9b, COUNTY
<br />9c, CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Codel
<br />9e. INSIDE CITY LIMIT;
<br />Nebraska
<br />Hall
<br />Wood River
<br />1208 Walnut 68883
<br />Yea ® No L_
<br />10 RACE - (e.g., White, BLAck, Arnerican Indian,
<br />11. ANCESTRY(,.g., Iter- Medcen, Getman. em.)
<br />12.® MARRIED ❑ WIDO WED
<br />13. NAME OF SPOUSE Ill wile, give maiden namel
<br />etc) (Specify)
<br />White
<br />(Speedv)
<br />German
<br />NEVER DIVORCED
<br />❑ M RRI D ❑
<br />Naomi Keiser
<br />14s.USUAL OCCUPATION - /Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION SPECFY ONLY HIGHEST GRADE COMPLETED)
<br />_
<br />Elem.merY Or SscormMry lO -121 ColNgs 114
<br />i o/ working life, even iI retired!
<br />`�B bar
<br />Barbering
<br />12 1
<br />- -- -� _
<br />16. FATHER NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Willie John Dean Elizabeth Bott
<br />18 . WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT NAME
<br />(Yes, no om unk I IH yes, give war emd detae of cerviceal
<br />WW II 07/01/42 to 10/01/45 Naomi Dean
<br />_YES _
<br />t196 INFORMANT MAILING ADDRESS )STREET OR R.F.O. NO., CITY OR TOWN, STATE. ZIP)
<br />1208 Walnut Wood River NE. 68883
<br />20. EMBALMER SIGNATURE & LICENSE NO. 21a. METHOD OF DISPOSITION 21 b. DATE 21, CEMETERY OR CREMATORY - NAME
<br />not embalmed ❑ 06/19/1996 Central Nebraska Cremation Service
<br />❑
<br />Bndd Removal
<br />22e. FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />A fel Funeral Home ® Llemalipn ❑ Op wtip^ Gibbon, Nebraska
<br />22h. FUNERAL HOME ADDRESS )STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIPI
<br />ood River NE. 68883 -126
<br />_W_
<br />23. PART IMMEDIATE CAUSE /1�/�y R C� ( (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ib)• AND (01 Interval between onset and death
<br />L' /'+ i t� O '•� I V 1 C71.
<br />lei
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and death
<br />DUE TO OR AS A CONSEQUENCE OF -� Interval between onset and death
<br />I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS Cammditione comributirg ro tM Math but net mebred PART
<br />III IF FEMALE WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICA(
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />If
<br />IAgn
<br />10 -54) Yea Na
<br />Yes No
<br />Yes
<br />26a.
<br />26b. DATE OF INJURY (Mo, Del, Y,.l
<br />26c. HOUR OF INJURY
<br />26d, DESCRIBE HOW INJURY OCCURRED
<br />L.J Accident Undetenhimd
<br />M
<br />S.- ❑ Pending
<br />26e. INJURY AT WOflK
<br />26f. PLACE OF INJURY - At home, term. .vest, factory
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STA IF
<br />Hormmicda Invsetipetion
<br />Vea No
<br />office building, etc. - ISpedlyl
<br />27a. DATE OF DEATH tMo, Day, Y.l 28a, DATE SIGNED (Me, Day, Y. 281, TIME Ol fEAS TH
<br />June 16 1996 M
<br />E
<br />3 = 27b. DATE SIGNED ( j,, Oqy, Yi l 27c. TIME OF DEATH i g Y 28c. PRONOLINCED DEAD (Me, Day, Y,.1 28d. PRONOUNCED DEAD niou,/
<br />NI
<br />F _ p'r> M
<br />t
<br />27d Tolle best of my know) ge, death occurred at the time,date and place and due to the j `[Re On the basis of examination and /or investigation, in myopirmion death occurred am
<br />o eslsl stated. C J� ,�I i� /' 1 ' errs time, tlate and place and due to [he cause(sl stated.
<br />` `-^' = IY �ISignature
<br />ISig nature and Title/ - and Title)
<br />i
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEAT 30a, HAS ORGAN OR TISSUE DONATION BEEN CgNSIDERED7 30b. WAS CONSENT GRANTED?
<br />fUNKNO
<br />YES NO ❑
<br />❑ WN VES ❑ VES NO
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