|
WHBV 7NIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPAR2*ZF I FAE4tTIL
<br />/T CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON JtrWFFH?I& TE;
<br />DEPAR77NENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE ( i A-06-
<br />VITAL RECORDS.
<br />DATE OF ISSUANCES
<br />JAN21 1997 200106599 == =s . EYs.COO
<br />ASS / STANT ST - - E R AR=
<br />LINCOLN NEBRASKA NEBRASKA DEPARTMENT -OF flE L ZII
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTFF=_
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />m
<br />4
<br />4, CITY AND STATE OF BIRTH /Mna n USA.. Hama eotetay)
<br />n
<br />n
<br />UNDER 1 DAY
<br />6. DATE OF GIRT /MOrdh. Day Year)
<br />MOS. I DAYS
<br />5c. HOURS' MIN$.
<br />Arcadia, Nebraska
<br />(Yrs,l 5b.
<br />69
<br />m
<br />-n
<br />1
<br />8a. PUCE OF DEATH
<br />507-38-5867
<br />HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Homo
<br />❑ ER OutpaBent rX1 Residence
<br />8b. FACILITY - Name /Moot maeh/fiort. gms street and nwnbar/
<br />-
<br />❑ DOA ❑ Other /8pecdyl
<br />Bc. CITY TOWN OR LOCATION. OF DEATH
<br />tld. INSIDE CITY LIMITS
<br />= D
<br />Grand Island
<br />$
<br />I Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />o
<br />9
<br />Nebraska
<br />_
<br />�
<br />Grand Island
<br />p
<br />Yea ® No ❑
<br />10. RACE - (e.g., White. &xk. American Indian,
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /M wda. 9rve maiden name/
<br />III (Smcifvl
<br />White
<br />i�
<br />N
<br />CD
<br />M (f)
<br />r) =
<br />N
<br />ii
<br />of working lit, even Mrekred) -
<br />Mill Worker
<br />Delicious Foods
<br />Elemernary or Secondary 10 -121 College 11 -4 or 5.1
<br />6th Grade
<br />16. FATHER - NAME FIRST MIDDLE UST 17.
<br />t-
<br />rG-
<br />;r 44
<br />�
<br />o
<br />CO
<br />mss.
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes, no. or unk.)
<br />III yes. give war and dates of serNCSsl -
<br />1
<br />No
<br />I - - --
<br />Donna F. Lybarger
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />o
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.,
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 2t
<br />t. CEMETERY OR CREMATORY - NAME
<br />t=
<br />�Bun.f ❑RemOwal
<br />4
<br />Westlawn Memorial Pik. CemE
<br />rn
<br />b
<br />❑ crema0pl ❑ Donatxx,
<br />Kleine Funeral Home
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)) Ineml between onset and death
<br />PAR' l Metastatic CA of the Colon. ; Approx.3 -4 month:
<br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death
<br />CD
<br />DUE TO, OR AS A CONSEQUENCE OF: I lnlorval between onset and death
<br />I
<br />(c)
<br />I
<br />PMT OTHER SIGNIFICANT CONDITIONS - Condikonq 10 the death Dut nd "W PART PART
<br />ASCVD
<br />III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />II 7 Longstanding�i- ypertension . PREGNANCY
<br />rn
<br />EXAMINER OR CORONER?
<br />C7)
<br />it
<br />Yes No
<br />Yes No
<br />26a,
<br />26b. DATIEE7OF INJURY /MO.. Day. Yr./
<br />28c. HOUR OF INJURY
<br />280. DESCRIBE MOW INJURY OCCURRED
<br />Accident � Undetermined
<br />N/A
<br />M
<br />Suicide E] Pending
<br />26e. INJURY AT WORK
<br />261. W.C=aUrcRV -( t hgpe, farm, street. factory
<br />o18e qY/
<br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />Homicide mvesugatbn
<br />yes ❑ No ❑
<br />27a. DATE OF DEATH /A46. Day. yr. /
<br />288. DATE SIGNED (Mo. Day Yr.)
<br />28b. TIME OF DEATH
<br />a<
<br />01 6-97
<br />a-1
<br />01 -13 -97
<br />W
<br />27b. DATE SIGNED /Ado.. Day. Yr/
<br />27c. TIME OF DEATH
<br />k
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yrl
<br />28d. PRONOUNCED DEAD /Hood
<br />01 -13 -97
<br />V 1
<br />"�
<br />r�
<br />27d. To the Deal of my k unad at Ste place and due ro the
<br />288. On etc basis of examination andtar Inveslgation, in my opinion death occurred N
<br />°
<br />ause(sl stated. _
<br />:Nand
<br />v 8
<br />the tine, date and place and due to that Came(s) slated.
<br />"
<br />(Signature and Title ►
<br />(Signature and Title
<br />29. -DID TOBACCO
<br />USE CONTRIBUTE TO ? 30.a
<br />HAS TISSUE DONATION BEEN
<br />CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ UNKNOWN
<br />❑ YES ®
<br />WHBV 7NIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPAR2*ZF I FAE4tTIL
<br />/T CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON JtrWFFH?I& TE;
<br />DEPAR77NENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE ( i A-06-
<br />VITAL RECORDS.
<br />DATE OF ISSUANCES
<br />JAN21 1997 200106599 == =s . EYs.COO
<br />ASS / STANT ST - - E R AR=
<br />LINCOLN NEBRASKA NEBRASKA DEPARTMENT -OF flE L ZII
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTFF=_
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />4, CITY AND STATE OF BIRTH /Mna n USA.. Hama eotetay)
<br />51. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF GIRT /MOrdh. Day Year)
<br />MOS. I DAYS
<br />5c. HOURS' MIN$.
<br />Arcadia, Nebraska
<br />(Yrs,l 5b.
<br />69
<br />July 2, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PUCE OF DEATH
<br />507-38-5867
<br />HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Homo
<br />❑ ER OutpaBent rX1 Residence
<br />8b. FACILITY - Name /Moot maeh/fiort. gms street and nwnbar/
<br />2327 W . 11th Street
<br />❑ DOA ❑ Other /8pecdyl
<br />Bc. CITY TOWN OR LOCATION. OF DEATH
<br />tld. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ®"� ❑
<br />I Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /includingiZpr Code)
<br />9e. INSIDE CRY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2327 W. 11th St. 68803
<br />Yea ® No ❑
<br />10. RACE - (e.g., White. &xk. American Indian,
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12. ® MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE /M wda. 9rve maiden name/
<br />III (Smcifvl
<br />White
<br />(Spec
<br />I German
<br />NEVER DIVORCED
<br />Donna F. Anderson
<br />14a, USUAL OCCUPATION /Give kind of work done dlai'g mod 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working lit, even Mrekred) -
<br />Mill Worker
<br />Delicious Foods
<br />Elemernary or Secondary 10 -121 College 11 -4 or 5.1
<br />6th Grade
<br />16. FATHER - NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Floyd L. Lybarger Dec.
<br />'fable NMI Anderson Dec.
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes, no. or unk.)
<br />III yes. give war and dates of serNCSsl -
<br />1
<br />No
<br />I - - --
<br />Donna F. Lybarger
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2327 W. 11th Street Grand Island Nebraska 68803
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO.,
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 2t
<br />t. CEMETERY OR CREMATORY - NAME
<br />j el 4z
<br />�Bun.f ❑RemOwal
<br />Jan. 9 1 1997
<br />Westlawn Memorial Pik. CemE
<br />22a. FUNE L HOME - NAME 1
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑ crema0pl ❑ Donatxx,
<br />Kleine Funeral Home
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND (c)) Ineml between onset and death
<br />PAR' l Metastatic CA of the Colon. ; Approx.3 -4 month:
<br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I61
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF: I lnlorval between onset and death
<br />I
<br />(c)
<br />I
<br />PMT OTHER SIGNIFICANT CONDITIONS - Condikonq 10 the death Dut nd "W PART PART
<br />ASCVD
<br />III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />II 7 Longstanding�i- ypertension . PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a,
<br />26b. DATIEE7OF INJURY /MO.. Day. Yr./
<br />28c. HOUR OF INJURY
<br />280. DESCRIBE MOW INJURY OCCURRED
<br />Accident � Undetermined
<br />N/A
<br />M
<br />Suicide E] Pending
<br />26e. INJURY AT WORK
<br />261. W.C=aUrcRV -( t hgpe, farm, street. factory
<br />o18e qY/
<br />26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE
<br />Homicide mvesugatbn
<br />yes ❑ No ❑
<br />27a. DATE OF DEATH /A46. Day. yr. /
<br />288. DATE SIGNED (Mo. Day Yr.)
<br />28b. TIME OF DEATH
<br />a<
<br />01 6-97
<br />a-1
<br />01 -13 -97
<br />9:20 AM
<br />27b. DATE SIGNED /Ado.. Day. Yr/
<br />27c. TIME OF DEATH
<br />k
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yrl
<br />28d. PRONOUNCED DEAD /Hood
<br />01 -13 -97
<br />9:20 A M
<br />"�
<br />M
<br />27d. To the Deal of my k unad at Ste place and due ro the
<br />288. On etc basis of examination andtar Inveslgation, in my opinion death occurred N
<br />°
<br />ause(sl stated. _
<br />:Nand
<br />v 8
<br />the tine, date and place and due to that Came(s) slated.
<br />"
<br />(Signature and Title ►
<br />(Signature and Title
<br />29. -DID TOBACCO
<br />USE CONTRIBUTE TO ? 30.a
<br />HAS TISSUE DONATION BEEN
<br />CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ UNKNOWN
<br />❑ YES ®
<br />NO
<br />❑ YES ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEVI /Type or Phnf/
<br />Steven L. Husen, D 2116 W Faidle v Ave. Grand Island NE 3
<br />32a. REGISTRAR - -
<br />326. DATE FILE 1 r/
<br />06,1 o
<br />t.
<br />\�Q
<br />
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