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<br />WHEN THIS COPY CARRIES THE RAISED SEAL
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE
<br />OF AN ORIGINAL RECORD ON FILE WITH THE
<br />BUREAU OF VITAL STATISTICS, WHICH IS T]
<br />VITAL RECORDS.
<br />OF THE NEBRASKA STATE
<br />BELOW TO BE A TRUE COPY
<br />STATE DEPARTMENT OF HEALTH
<br />3E LEGAL DEPOSITORY UR
<br />200106543 -_ =-
<br />DATE OF ISSUANCE - _ _-
<br />MAY 2 5'.` STANLEY f DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU VI STATISTICS-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 [DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX 3. DATE OF DEATH (Month. r +y, Ywl
<br />Leo James Caffery
<br />Male May 16, 1993
<br />a. CRY AND STATE OF SIRTH p,nain (,SA, rsmor malay) SL AGE • Law Bkiday
<br />MOS.
<br />8. GATE OF BIRTH /Month. pay Year)
<br />(Yn 5b. DAYS
<br />Spalding, Nebraska 75
<br />5C. HOII :� MINS.
<br />;. Nov. 9, -917
<br />7. SOCIAL SECURITY MMCR
<br />fa. PLACE OF DEATH EJ hhpatlem ❑ ER /OlApallonl ❑DOA
<br />MOSPRAL
<br />506 -18 -3150
<br />\ OTHER. ❑ Noralrlg Hem. ❑ Residence ❑ OIMr(SV.d*l
<br />•. FACILITY - Name tw not mmvko ar( give so" and naolbp)
<br />Sc. CRY, TOWN OR LOCATION OF DEATH
<br />Bit. INSIDE CITY LIMITS
<br />M. COUNTY OF DEATH
<br />St. Francis Medical Center
<br />Grand Island
<br />( Yes a �'
<br />Hall
<br />I
<br />Be. RESIDENCE - STATE
<br />ib. COUNTY
<br />9c. CRY. TOWN OR LOCATION
<br />fd. STREET AND NUMBER /Mckdhp Zp Coda)
<br />M. INSIDE CITY UMRB
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1222 E. 7th
<br />`SPYes a"f'
<br />10. RACE - (e.g, Whet. Okwk Amwkw Indian,
<br />ANCESTRY (e.g.,Nafen, Mexican, German, ek.)
<br />12. MARRIED,NEVER MARRIED,
<br />NAME OF SPOUSE (M wMe, givr maiden name)
<br />etal lsPacrrl,
<br />111.
<br />ISDedYI
<br />`t� b
<br />WIDOWED, DIV ED (SSpetty)
<br />d
<br />113.
<br />White
<br />American
<br />Marri
<br />Mary Margaret Nunez
<br />to USUAL OCCUPATION lGlve Idrld a/ aura will daerg most
<br />KIND OF BUSINESS INDUSTRY
<br />d fivarso
<br />Foreman
<br />114b.
<br />Paine Monument Co.
<br />ENm�Wy a Secondary (0.12) I Coati 11-! a S•(
<br />8 I
<br />14. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />John Caffery I
<br />Margaret Palmer
<br />18. WAS DECEASED
<br />EVER W U.S. ARMED FORCES?
<br />FORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR JQIBM$T{ITE, ZIP)
<br />1Yes, no. a linkI
<br />P Yea,"war and do" a Services)
<br />W91 �0d8�aVVJ1
<br />Yea: 8-
<br />-41 1- 30-45
<br />y Margaret Caffery -1222 E. 7th -Grand Island, NE
<br />2h. BINBAL, CrmhaaahArrhsvat,
<br />Oalaaon
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME Md.
<br />LOCATION CITY OR TOWN STATE
<br />Burial
<br />May 20, 1993
<br />Westlawn Memorial Park
<br />Grand Island, NE.
<br />21. - SIGMA i LICENSE NO.
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN, STATE, ZIP)
<br />fel- Butler- Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />,
<br />ON
<br />)MEDIATE CAUSE (ENT R ONLY E CAUSE PER LINE FOR (a), (b). AND (c)) I Interval between onset and death
<br />PART
<br />I I
<br />DUE TO.OR AS A ENCE OF: I Inimal between onset and death
<br />I
<br />8 Hours
<br />DUE .TO, OR AS A CONSEQUENCE OF: I Interval between onnt and death
<br />I
<br />�=r-Etminsjvp- Cardin Vagrular Di 10 Yea
<br />OTHER-SIGNIFICANT CONDITIONS - C -diia s canbiMron010 death bill not r tM
<br />PART
<br />PART IB IF FEMALE, WAS THERE A
<br />2e. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />B
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Spaeth* Yes a Nd)
<br />EXAMINER OR CORONER?
<br />Yee ❑ No ❑
<br />0
<br />(SP c� No a No)
<br />j�
<br />Ms. ACCIDENT, SUK2DE. HOMICIDE, UNDET.,
<br />28D. DATE OF INJURY (Ab.•Day Yr.)
<br />28c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Sped*)
<br />NA--
<br />- - - - --
<br />- - - - --
<br />-- --- --
<br />2Be. INJURY AT WORK
<br />281. PLACE OF INJURY • At Mme, farm, street, lacbry,
<br />280. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />(SP-#Y Yee or Aw
<br />- - - - - --
<br />office building. etc. (Spedi*)
<br />I ------- - - - - --
<br />------ - - - - --
<br />27a. DATE OF DEATH (Ma. Day, Yr.)
<br />28s. DATE SIGNED (Ma, Day, Yr.)
<br />29b. TIME OF DEATH
<br />May 16, 1993
<br />Is
<br />a
<br />a
<br />27b. DATE SIGNED (Ma, Day, Yr.)
<br />270. TIME OF DEATH
<br />2&. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />28a PRONOUNCED DEAD (Hour)
<br />�
<br />May 20, 93
<br />•
<br />a
<br />e
<br />E Q
<br />27d. To the best d my death fccumd et time pace and due to IM
<br />w4/or
<br />280. On the basis a examhnstrow4/or InveebgWon, in my opinion death occurred at
<br />awN81 paced. i
<br />$$ is
<br />Rile time, dsfa and pace and this to tM auwls) staid.
<br />rd ram, / 2 �-•��
<br />SI nature and Title
<br />26L O10 TOBACCO USE CONMJIUTE TO THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />❑ YES X NO O UNKNOWN
<br />O YES x NO
<br />2 YES XI NO
<br />.,..�....,.., ....•..mow ,T ...� h , .�..�....,...,,..�., � . . . . ............. ............, ,,,..,.. r h �,r � �, ,,.,
<br />Gordon F antis M. P. 721 W. 7th, Grand Island, NE. 68801
<br />Us. REGISTRAR /J� �.J 32b. DATE FILED BY REGISTRAR (Mo. Daey, Yr.)
<br />
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