|
M
<br />2 D
<br />C7
<br />M 2
<br />M (/)
<br />r) _
<br />V!
<br />r JG
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Year)
<br />Marjorie Mae Good
<br />Female
<br />•
<br />4. CITY AND STATE OF BIRTH IMnot in USA. name aouneY)
<br />So. AGE - Leal Birthday
<br />G1
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH (Monde, Day. Year)
<br />Nance County, Nebraska
<br />(Y "' 67 so.
<br />July 29, 1929
<br />MoB DAYS
<br />SaHOUgS; MlNS
<br />7. SOCIAL SECURTIY NUMBER
<br />Bill. PLACE OF DEATH
<br />h
<br />HOSPITAL 1:1 Inpatient OTHER Nursing Home
<br />El ER Outpatient Residence
<br />Care
<br />8b. FACILITY - Name (d not mshaulion give sheaf and nrumbeq
<br />St. Francis Skilled Bare Unit
<br />❑ DOA a„8,(killed
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />yes E?f ❑
<br />Hall
<br />No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncludinrg 1p Cade)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1305 N. Sheridan 68
<br />04.n
<br />10. RACE -fag., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian, Mexican. German, elcl
<br />12. 13 MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (n -we. give maiden name)
<br />i le
<br />Cn
<br />LT NEVER DIVORCED
<br />MARRIED F]
<br />James Good
<br />14a USUALOCCUPATION (Give kind of work done dtakg moat
<br />K IND OF BUSINESS INDUSTRY
<br />t 5. EDUCATION (Specify only highest grade completed)
<br />EN ary 10 -121 � College 11 -4 or 5.1
<br />"1"f d
<br />d working ft even d named)
<br />Telephone Operator
<br />rb elephone Company
<br />16. FATHER -NAME FIRST MIDDLE UST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Boardman
<br />Bertha Swartz
<br />S. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. ro. or unk.) in yes. give war and dates d service it
<br />No
<br />Jim Good
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1 05 Sheridan Place Grand Island, Nebraska 68803
<br />20. MER - S LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />%TUR
<br />�&aial ❑Removal
<br />March 22,1 9 7
<br />-Grand Island Cemeter,
<br />NE E - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Palmer's Funeral Home
<br />��°"�°" �°°na "°
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR FLF.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />210 Irving Street Fullerton Nebraska 68638
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR dal. Ibl. AND (cl) Interval between onset and death
<br />,
<br />PART < S
<br />'
<br />k
<br />(al J i
<br />a DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />fbl
<br />i
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me death but not related P ART
<br />111 IF FEMALE. WAS THERE A 2
<br />UTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />AMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />Yes NO
<br />Yes No
<br />t
<br />RJ3
<br />Lot 18, Imperial Village Third Subdivision, Hall County, Nebras]4g.
<br />WHEN TM COPYCARRES 714E RAISED SEAL OF THE NEBRASKA HEALTH AND N SER
<br />SYSTEM IT CERTFES TIf BELOW TO BE A TRUE COPY OF THE ORIGINAL RE_V*ftkOR W
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC A@97�� =_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE /_
<br />APR 11997 209,0069-06 , ,'� --
<br />AsslsrAl�r
<br />UNCOLN,NEBRASKA HEALTHANDHUMA# 1
<br />STATE OF NEBRASKA DEPARTMENT OF HEALT/�
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE UST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Year)
<br />Marjorie Mae Good
<br />Female
<br />March 19 1997
<br />4. CITY AND STATE OF BIRTH IMnot in USA. name aouneY)
<br />So. AGE - Leal Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH (Monde, Day. Year)
<br />Nance County, Nebraska
<br />(Y "' 67 so.
<br />July 29, 1929
<br />MoB DAYS
<br />SaHOUgS; MlNS
<br />7. SOCIAL SECURTIY NUMBER
<br />Bill. PLACE OF DEATH
<br />506-32-8668
<br />HOSPITAL 1:1 Inpatient OTHER Nursing Home
<br />El ER Outpatient Residence
<br />Care
<br />8b. FACILITY - Name (d not mshaulion give sheaf and nrumbeq
<br />St. Francis Skilled Bare Unit
<br />❑ DOA a„8,(killed
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />yes E?f ❑
<br />Hall
<br />No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncludinrg 1p Cade)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1305 N. Sheridan 68
<br />04.n
<br />10. RACE -fag., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian, Mexican. German, elcl
<br />12. 13 MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (n -we. give maiden name)
<br />i le
<br />(B�d�yl German
<br />LT NEVER DIVORCED
<br />MARRIED F]
<br />James Good
<br />14a USUALOCCUPATION (Give kind of work done dtakg moat
<br />K IND OF BUSINESS INDUSTRY
<br />t 5. EDUCATION (Specify only highest grade completed)
<br />EN ary 10 -121 � College 11 -4 or 5.1
<br />"1"f d
<br />d working ft even d named)
<br />Telephone Operator
<br />rb elephone Company
<br />16. FATHER -NAME FIRST MIDDLE UST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Boardman
<br />Bertha Swartz
<br />S. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. ro. or unk.) in yes. give war and dates d service it
<br />No
<br />Jim Good
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1 05 Sheridan Place Grand Island, Nebraska 68803
<br />20. MER - S LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />%TUR
<br />�&aial ❑Removal
<br />March 22,1 9 7
<br />-Grand Island Cemeter,
<br />NE E - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Palmer's Funeral Home
<br />��°"�°" �°°na "°
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR FLF.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />210 Irving Street Fullerton Nebraska 68638
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR dal. Ibl. AND (cl) Interval between onset and death
<br />,
<br />PART < S
<br />'
<br />k
<br />(al J i
<br />a DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />fbl
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me death but not related P ART
<br />111 IF FEMALE. WAS THERE A 2
<br />UTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />AMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />Yes NO
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Ale.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined
<br />M
<br />D Sux:ide [:] Pending
<br />26e. INJURY AT WORK 1
<br />261. ol6ce E INJURY /At hof. , farm. street. factory
<br />olfiC ten SPecn1'1
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide investigation
<br />Yes � No �
<br />27a. DATE OF DEATH /qMO. Day. ✓r)
<br />28a. DATE SIGNED /MO. Day YrI
<br />28b TIME OF DEATH
<br />ES
<br />_ `
<br />S z
<br />g
<br />M
<br />27b. DATE SIGNED (Ale.. Day Yr.I
<br />27c. TIME OF DEATH 6Lj
<br />28c. PRONOUNCED DEAD /Ale_ Day, Yr)
<br />28d. PRONOUNCED DEAD (hbol
<br />fir
<br />A. A1,
<br />M
<br />S
<br />8
<br />.
<br />27d. To the Dent d my k death occurred
<br />t ti and pica arnd due b the
<br />280. On the basis d examination and,a investigation, in my opinion death occurred at
<br />cause( sl s0.0.1 `, ^y_\
<br />* l -
<br />\I�Y�
<br />1
<br />c� 6
<br />the ante, date and dace and due to the causelsl stated.
<br />(S' nature and Title 1 ' 1
<br />-
<br />S- nature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO HF �EATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />YES Z "� � UNKNOWN
<br />YES 10
<br />YES 5'140
<br />31. N/tMY AND ADDRESS OF CERTIFIER IPHVSICIAN.COfgNER'S PHYSICIAN O�� ORNEY1 /Type or Prim/
<br />\►1(�/ ,rj ^/\
<br />r�� 6 Xn
<br />jI
<br />--
<br />I 32a. REGISTRAR _ _ _
<br />32D. DATE FILED BY REGISTRAR
<br />A "Hy 1§97
<br />1
<br />ro
<br />C3.
<br />CD N
<br />C7
<br />C-J
<br />O CCD
<br />Cn
<br />s•so
<br />
|