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<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH.J_ r .
<br />2000CIt 477 -1
<br />DECEASED —NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE OF DEATH I MONTH, DAY, YEAR 1
<br />Norman William Roever
<br />Male
<br />April 99 1977
<br />1,
<br />7
<br />7,
<br />RACE WHITE, NEGRO, AMERICAN INDIAN,
<br />AGE —IAS1
<br />UNDER I YEAR
<br />UNDER 1 DAr
<br />M
<br />COUNTY OF DEATH
<br />D
<br />DAYS
<br />HOURS
<br />MIN,
<br />ETC. 1 SPECIFY 1
<br />tI RIH DA 1 YEARS
<br />�1
<br />I
<br />YEAR I
<br />April 69 1916
<br />Hall
<br />,. white
<br />C
<br />S►.
<br />Sc.
<br />,.
<br />,,.
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />INSIDE CITY LIMIT$
<br />2
<br />1
<br />Grand Island I,,
<br />Z
<br />ac
<br />»
<br />,d
<br />c�
<br />cn
<br />o
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (GIVE KIND OF WORK DONE DURING MOST OF KIND OF BUSINESS OR INDUSTRY
<br />(
<br />b
<br />RESIDENCE —STATE COUNTY CITY, TOWN, OR LOCATION INSIDE CITY LIMITS STREET AND NUMBER
<br />Neb. Hall 114, Grand Island SPE0NY -Tes No] 2516 W. Cottage
<br />IRR. I /b. . Ltd. Ile.
<br />FATHER - -NAME FIRST MIDDLE LAST
<br />MOTHER — MAIDEN NAME FIRST MIDDLE LAST
<br />Herman Roever
<br />c) -j
<br />,,,
<br />c�v
<br />r)
<br />2
<br />N
<br />PART I. DEATH WAS CAUSED BY: ENTER ONLY ONE CAUSE PER LINE FOR D , b , AND c
<br />I ( % ( % ( JI
<br />Arr3N ONSET IN D
<br />of rw EEO ONSET AND V ATII
<br />If IMMEDIATE CAUSE
<br />�;
<br />s
<br />1
<br />N
<br />ca
<br />`
<br />CONDITIONS, IF ANY,
<br />D,
<br />/
<br />WHICH CAVE RIS! TO Ib) 7
<br />IMMEDIATE CAUSE 101, DU! 10, OR AS A CONSEOUl NC O/:
<br />Sr ATING IHE UNDER- �)
<br />LYING CAUSE LAST E _
<br />IC) tA
<br />PART II. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATE
<br />PART III. If FEMALE, WAS THERE A
<br />AUTOPSY
<br />IF YES wFRF FI INGS CON.
<br />TO CAUSE GIVEN IN PART I(a)
<br />PREGNANCY IN THE PAST J MONTHS?
<br />I YES OR NOT
<br />�J
<br />O
<br />N
<br />Ifi. 'y
<br />-H
<br />I%.
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />OF INJURY (MONTH, DAY, YEAR I
<br />HOUR
<br />HOW INJURY OCCURRED I ENTER NATURE OF INJURY IN PART 1 OR PART It, ITEM 111
<br />OR UNDETERMINED I SPECIFY)
<br />JDATE
<br />O -11
<br />O
<br />•--
<br />70b.
<br />70c. M.
<br />20d.
<br />INJURY AT WORK
<br />0
<br />'Tt
<br />f
<br />O
<br />T—
<br />O
<br />701.
<br />t09 /
<br />CERTIFICATION— Mo.7m DAY YEAR MONTH DAY YEAR AND
<br />LAST SAW H;M/HER ALIVE ON
<br />I DID /DID 101 VIEW THE
<br />DEATH OCCURRED AT THE PLACE, ON THE
<br />►H YSICIAN:
<br />7/� TO r.� 7
<br />I ATTENDED THE _
<br />.r
<br />O
<br />1? Lj
<br />O
<br />— 71
<br />_
<br />tld.
<br />tlE TO THE CAUSE(S) STATED.
<br />j CERTIFICATION— MEDICA EXAMINER OR CORONER: ON THE BASIS Or 1H1 HOUR OF DEATH
<br />THE DECEDENT WAS PRONOUNCED DEAD
<br />EXAMINATION OF ME BODY AND�OI THE INVESTIGATION, IN MY OPINION,
<br />MONTH DAY YEAR HOUR
<br />DEATH OCCURRED ON ME DATE AND DUE TO THE CAUSEISI STATED.
<br />77, M.
<br />I 77b. M.
<br />CERTIFIER —NAME mPE OR PRJNn
<br />SIG E
<br />of E YOR nn DATE SIGNED (MONTH, DAY, YEAR)
<br />7t. C Dean McGrath M
<br />to
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<br />r 1>
<br />rn
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<br />rs,
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<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH.J_ r .
<br />2000CIt 477 -1
<br />DECEASED —NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE OF DEATH I MONTH, DAY, YEAR 1
<br />Norman William Roever
<br />Male
<br />April 99 1977
<br />1,
<br />7
<br />7,
<br />RACE WHITE, NEGRO, AMERICAN INDIAN,
<br />AGE —IAS1
<br />UNDER I YEAR
<br />UNDER 1 DAr
<br />DATE OF BIRTH (MONTH, DAY,
<br />COUNTY OF DEATH
<br />I THOS.
<br />DAYS
<br />HOURS
<br />MIN,
<br />ETC. 1 SPECIFY 1
<br />tI RIH DA 1 YEARS
<br />�1
<br />I
<br />YEAR I
<br />April 69 1916
<br />Hall
<br />,. white
<br />S,
<br />S►.
<br />Sc.
<br />,.
<br />,,.
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />INSIDE CITY LIMIT$
<br />HOSPITAL OR OTHER INSTITUTION —NAME (IF NOT IN EITHER, GIVE STREET AND NUMBER 1
<br />1
<br />Grand Island I,,
<br />Srf CITY YES OR No
<br />Yes
<br />Lutheran Memorial Hospital
<br />»
<br />,d
<br />STATE OF BIRTH 1 II NOT IN V.S.A., NAME CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, SURVIVING SPOUSE I If WIFE, GIVE MAIDEN NAME 1
<br />COUNTRY 1 WIDOJZ� D�IiR D ( Sr ECUY 1
<br />Kansas U. S. A. jlVVjg� Anna E. Moser_
<br />,. 1, �e(� ,,
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (GIVE KIND OF WORK DONE DURING MOST OF KIND OF BUSINESS OR INDUSTRY
<br />WORKING tiff, EVEN If RETIRED)
<br />I7 511 12 3273 17, Mechanic (Retired),,*,," Ub. Motor Repairing
<br />RESIDENCE —STATE COUNTY CITY, TOWN, OR LOCATION INSIDE CITY LIMITS STREET AND NUMBER
<br />Neb. Hall 114, Grand Island SPE0NY -Tes No] 2516 W. Cottage
<br />IRR. I /b. . Ltd. Ile.
<br />FATHER - -NAME FIRST MIDDLE LAST
<br />MOTHER — MAIDEN NAME FIRST MIDDLE LAST
<br />Herman Roever
<br />Holle
<br />,,,
<br />ISb1a
<br />R-Bi U4. -ARMED FORCES: -_— __ENFOILMANT - NAME -- P^ELATION5H7P— MAILING ADDRESS „n,E� GB a.r a. r.., , C:r. — Icy -�.,
<br />(Yes, no, or unknown) (If Yea, give war and dales of se ;_,
<br />E. Roever 16 W.Cott Grand Island Ne. £
<br />no no 17. Anna -s ouse -2
<br />PART I. DEATH WAS CAUSED BY: ENTER ONLY ONE CAUSE PER LINE FOR D , b , AND c
<br />I ( % ( % ( JI
<br />Arr3N ONSET IN D
<br />of rw EEO ONSET AND V ATII
<br />If IMMEDIATE CAUSE
<br />IDI Cc Xez
<br />L
<br />R AS A CONSEO N ! 1:
<br />l
<br />`
<br />CONDITIONS, IF ANY,
<br />D,
<br />/
<br />WHICH CAVE RIS! TO Ib) 7
<br />IMMEDIATE CAUSE 101, DU! 10, OR AS A CONSEOUl NC O/:
<br />Sr ATING IHE UNDER- �)
<br />LYING CAUSE LAST E _
<br />IC) tA
<br />PART II. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATE
<br />PART III. If FEMALE, WAS THERE A
<br />AUTOPSY
<br />IF YES wFRF FI INGS CON.
<br />TO CAUSE GIVEN IN PART I(a)
<br />PREGNANCY IN THE PAST J MONTHS?
<br />I YES OR NOT
<br />�J
<br />St DEATH IN DEIE MINING CAUSE
<br />OF DEAi
<br />YES LJ NO LJ
<br />Ifi. 'y
<br />-H
<br />I%.
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />OF INJURY (MONTH, DAY, YEAR I
<br />HOUR
<br />HOW INJURY OCCURRED I ENTER NATURE OF INJURY IN PART 1 OR PART It, ITEM 111
<br />OR UNDETERMINED I SPECIFY)
<br />JDATE
<br />`-
<br />7011
<br />70b.
<br />70c. M.
<br />20d.
<br />INJURY AT WORK
<br />PLACE OF INJURY AT HOME, FARM, STREET, FACTORY,
<br />Pp
<br />LOCATION 1 fiREfT OR R.F.D. NO., CITY OR TOWN, STATE 1
<br />I SPECIFY r" OR NOI
<br />CE LLD.., ETC .SPECity,
<br />toe
<br />701.
<br />t09 /
<br />CERTIFICATION— Mo.7m DAY YEAR MONTH DAY YEAR AND
<br />LAST SAW H;M/HER ALIVE ON
<br />I DID /DID 101 VIEW THE
<br />DEATH OCCURRED AT THE PLACE, ON THE
<br />►H YSICIAN:
<br />7/� TO r.� 7
<br />I ATTENDED THE _
<br />MONTH DAY YEAR
<br />G C, "' .. /y
<br />BODY AFTER .D wM:l
<br />(HOUR) J� DATE, AND, r0 Tiff BEST
<br />EL-� OF MY KNOWIEDGf, DUE
<br />J — / 71,
<br />71, DECEASED (ROM ' ( 6) tl b. I
<br />— 71
<br />_
<br />tld.
<br />tlE TO THE CAUSE(S) STATED.
<br />j CERTIFICATION— MEDICA EXAMINER OR CORONER: ON THE BASIS Or 1H1 HOUR OF DEATH
<br />THE DECEDENT WAS PRONOUNCED DEAD
<br />EXAMINATION OF ME BODY AND�OI THE INVESTIGATION, IN MY OPINION,
<br />MONTH DAY YEAR HOUR
<br />DEATH OCCURRED ON ME DATE AND DUE TO THE CAUSEISI STATED.
<br />77, M.
<br />I 77b. M.
<br />CERTIFIER —NAME mPE OR PRJNn
<br />SIG E
<br />of E YOR nn DATE SIGNED (MONTH, DAY, YEAR)
<br />7t. C Dean McGrath M
<br />to
<br />( nE %
<br />3dILING AUUKtbb— CEI7TIPIfR 2 No. Custer Grand-Island Neb. 68801
<br />BURIAL, CREMATION, REMOVAL CEMETERY OR CREMATORY —NAME LOCATION CITY OR TOWN STATE
<br />1 SPECIFY 1
<br />I S Burial 241E I C' 7,c. Grand Island Neb.
<br />DATE (MONTH, DAY, YEAR( I FUNERAL HOME —NAME AND ADDRESS ( STREET of R.F.D. NO., CITY 01 TOWN, STATE, ZIP 1
<br />II EMBALMER— SIGNATURE 6 LICENSE NO. REGISTRAR— SIGNATURE DATE L .1 ! RERE/ GGGIST/RAR
<br />5 766 � ! /
<br />'7
<br />Jet
<br />WHEN ^THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STAfirE;DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE_;OPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS ^,"' LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued April 18, 1977
<br />
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