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Rev 1194 STATE OF NEBRASKA — DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS - CERTIFICATE OF DEATH I— ,, z, W' 0' W U W 0. u- 0. W Q Z I 6 Cl) 1 DECEDENT - NAME FIRST MIDDLE LAST 2. SEX J. DATE OF MATH (Monde Div Yowl Charles _ Leonard Hall M September 5, 1994 CH v AND STAI E OF BIRTH /n nd k USA. neme! crArorryl Se AGE - Last BlrMdey I UNDER i YEAR UNDER t DAY _ 8. DATE OF BIRTH /AIbn/F fist Y~1 Portland, Oregon (Yral Sb 83 MOS DAYS ' Sc. HOURS' MINS July 18 1911____ 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 504 03 5141 HOSPITAL: © Inpaeem OTHER O fsp..MH.- —.. ... El ER Out .,d - -- � Residence Ab FACILITY . NO— /n nnr msriAnierr, 9- shear and m-bw) VA Medical Center 1:1 DOA Dow (Sr-4, 8c CITY TOWN OR LOCATION OF DEATH 8d, INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand Island Yes 0 � Hall No 9e. RFSIDENCE STATF qh COUNTY 9c CIIY.TOWNORLO(:ATION 9d STREET AND NUMBER lkrAaknp 7//r ('Mal Oe MSIDF CeTV tisnre Nebraska Hall Grand island Nebraska Veterans Home � U res FAr 10 RACE le g, While Black, American MWian. 11. ANCESTRY Ieq. Malian. Mevecan, German, edd 12. E3MARMED r", WIDOWED 13 NAME OF SPOUSE /a-I. a"mabtn nw•nN ek.) 114w y) White IS1+ecAy1 Irish NEVER LJ DIVORCFD 1 Viola Endres M 14a USUAL OCCUPATION 1Grve kvd or- * nbrre during Oros) tab KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpectly oNy graft compleledl d ndkap Me. awn n revirMl Laborer Construction F—a aSeeoGr 1B ,21 Co 1a9e 11 .n M1•I �th Grade 19 FATHER -NAME FIRST MIDDLE LAST 17 __ _ MOTHER FIRST MIDDLE MAIDEN SUR M NAE dec Patrick NMN O'Donnell I (dec) Ellen NMN Riggley - 19 WAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT- NAME IYes na a unk.l IM yes give -ar and dales d services) Yes WWII /Army/1 1 /10142-12/6/4 Viola Hall t9b INFORMANT MAILING ADDRESS IST RFET OR RFD NO. CRY OR TOWN, STATE. ZIP( 2624 West 1st Grand island NE 68803 20 EM LM - SINAI E A LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CRFMATORY NAME ®Barra, �RemoYal Sept. 8,1994 Westlawn Memorial Park 22, . FUNERAL AME 21d. CEMETERY OR CREMATORY LOCATION CRY OR TOWN StATf Livingston - Sondermann F.H. ElCremnlbn El Oooakon Grand Island, Nebraska 2211, Fl /NERAIL HOMF ADDRF SS ISIREET OR RF.D. NO CITY OR TOWN, STATE, ZIP) 505 West Koenig, Grand Island, Nebraska 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial, IN. AND 1c)) I Meer vet br -wren m�r•e a.rr d.•.n,- DIRT Cancer of the Lung with Metastasis 1 5 months lei ; 091E 70. OR AS A CONSF.OUENCE OF I e4erval bet -ern awl aM —W, 1 roI 1 DUE 10. OR AS A CONSEOUENCE OF 1 MrbrvN bel wren o-m a,M M.>f•• 1 I Ic) , OTHFR SIGNWICANT CONO1/10NS - CadMlons C0r*tulirg b The death tail not related PART PART e1 1F FEMALE. WAS THERE A 21 AUTOPSY 25 WAS CASE REFERRED TO MFUIr AI PREGNANCY I Pneumonia IN THE PAST J MONIHS7 EXAMINER OR COR()HFR> )Ages 10 -511 Yes 11 Fb E] Vey 11 No Yes 11 No ki no 28b DATE OF INJURY (W Day. Yr/ 28c HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED 11 AccldMa ❑ lhdet -pined . M sucide [—] Peaknq 2Fis INJURY AT WORK 2611 PLAe E QF_ INJ� Y %A1 tg . farm, sheet. tacl0ry o1��cc bnWMl9 SMce71'I 289. LOCATION STREET OR R F D NO CIIY OR TOWN S A TF Hommide Invesligalinn Yes[:] No 1 27a DATE OF DEATH tW Day W1 29e. DATE SIGNED /AM. Day Yr 1 211b TIME OF DEATH • E Q E M 27b DATES NEO /Ab. Day nl 27c TIME OF DEATH 28c PRONOUNCED DEAD 1AM Day Y) _ _ 28d PRONOUNCED TIFAD M•�r L k K�9 FS E Qnr�er 5. 199 M __.M 29e, On IM basis of e•aminahm and or Invesagalion, in my ephow deelh attuned M 27d To IM bast d my knowlerlpe. deAet occurred Iha ems, Aal4 end place a due lo IM es-1.1 Of~ / , // /�" „V/ is are ems. slab and Plata and due b 1M causalsl staled. I O"Tllle and Tab ?9. 0911 TOBACCO USE CONTRIBUTE TO ThEVEMITH17 130. DONATION BEEN SIDERED? 30.b WAS CONSENT GRANTEDT ® YES El NO 0 UN 1:1 YES 621- YES ND 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER S PHYSICIAN OR COUNTY ATTORNEYI /Type or P" Charles Lye, M.D., VA Medical Center, 2201 N. Broadwell, Grand Island, NE 68803 324 REGISTRAR J2b DATE FILED Br REGISTRAR P. Day W/ FOR VITAL STATISTICS USE ONLY Place... .................... A .. ..............................B ................................ C ................................ D ................................ E ..... ...........................Part II ......................TMV ......................... NSC................................................................................................................................................................................................................... ............................... Census Tract No. Work. ............................... ............................................................................... ............................... . UC ............................................................................................................ ............................... Rejett.......................................................:........................................... ............................... a,11nI d -Nis aey ba — nettled POW • Reg. of Deeds hereby ceriify this to be a true and correct copy of the original fi,e, wlv h the State of Nebraska by Signed in my of Notary Public III UENERAL NOTARY -State of Nebraska TERRY L. N ` ............ MY Comm. Exp. ..