|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE KWASKALSTATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TQ - A,'iTVE'COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STM.- A K'.0 -HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE
<br />VITAL RECORDS.
<br />0000 72 54
<br />DATE OF ISSUANCE
<br />06 STANI, �D 1RECTOR
<br />AUG
<br />4
<br />LINCOLN, NEBRASKA BUREAU ..t.STATISTICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />CD
<br />0
<br />MIDW I LAST
<br />SEX
<br />(Mo.. Day. Yr.)
<br />Charles Boyce King
<br />12.Male
<br />3.JUlY 18, 1985
<br />"CE - (e.g., White, Black, American
<br />(e.g., Italian, Mexican' AGE
<br />-Last ti,*Av
<br />L_UNDER I YEAR I
<br />UNDER I DAY
<br />I DATE OF BIRTH (Mo., Day, Yr.)
<br />mos.
<br />;0
<br />wic , •k.) (Specify)
<br />JORIGIN/DESCENT
<br />Gorman, &k.) (Specify) (Yr$)
<br />41 White
<br />5. American Q
<br />is
<br />1".
<br />M
<br />CFFT AND STATE OF IHUH (IF not in U.S.A..
<br />4
<br />CMU" Or Wwky-COUNTIRPMA
<br />NEVER MARRIED,
<br />OF SPOUSE (N wife, give maiden name)
<br />i[
<br />0. DIVORCED (Specify)
<br />Knoxville, Tennessee '
<br />C
<br />2
<br />M
<br />Susan A. Sorensen
<br />a
<br />SOCIAL SECURITY HUMBER
<br />SUAL OCCUPATION (Give kind of work done dvring most ND
<br />gorensen
<br />OF BUSINE$S ORfrIaSTRY
<br />COUNTY OF DEATH
<br />of working life, even if retired)
<br />113a. 113b.
<br />s 0 y
<br />zn
<br />(1)
<br />PC
<br />Foreman
<br />ShQp
<br />c::)
<br />o
<br />CD
<br />- In es r,
<br />M
<br />A
<br />(Specify Yes or No)
<br />give shee and number)
<br />Ov•ti•fleme, . I.Poti..v (Specify)
<br />i4b. Grand Island
<br />i4c. Yes
<br />14d.St- Francis Medical Center )4..
<br />Emer. Room
<br />SVENCE-STATE COUNTY
<br />CITY, TOWN OR LOCATION
<br />XU)
<br />I NSIDf CITY LIMITS
<br />,so. Nebraska 1i5b. Hall
<br />,Sc. Grand Island
<br />it". 1706 N. Taylor
<br />I (spssci To ' or No)
<br />So. es
<br />__q M
<br />MOTHER -MAIDEN NAME FIRST MIDDLE LAST
<br />V11
<br />117,
<br />Charles Henry, King
<br />Mary Margaret King
<br />WAS DECEASED MR IN U.S, ARMED FORCEP
<br />INPOW"NT - NAME - RELATIONSHIP - MAILIV40 ADDRESS JSTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIM
<br />(Vs% ... . took) I (it yet, gi�* ", and dafts of -ke)
<br />Dusan A. King-Wife-1706 N. Taylor-Grand Island, NE.688(
<br />to Yes B-31-59/4-30-62
<br />CD
<br />110-&AL, Cremation, Removall
<br />DATE
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION cl TY 01 TOWN STATE
<br />July 22 1985
<br />,
<br />ne, Burial
<br />20b.
<br />2oc. Westlawn Memorial Park
<br />Grand Island, NE.
<br />["A 51GNAT RE U SE N
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />/
<br />fel-Butler-Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />21 12
<br />CD
<br />DATE SIGNED (Mo. Day, Yr.)
<br />HOUR OF DEATH
<br />fir
<br />24a. 124b
<br />U1
<br />_T1
<br />CD
<br />jm5m W 6UT14
<br />dy'- ZF
<br />I
<br />PRONOUNCED DEAD PRONOUNCED
<br />Y-r.j
<br />DEAD (Hour)
<br />23b. 23c. M
<br />VtZ
<br />24.. 24d.
<br />M
<br />To the best .1 y k-1 IPF ti"��79 e.Ad1ZNh&
<br />:�,,
<br />On Is. basis of ...inesen o. iz=. opinion siseth occ-d of
<br />•
<br />t.
<br />cm,*0 sftftd.
<br />•
<br />the It", date and Place end dws, I. I=
<br />its) M
<br />4 r, L
<br />1=R_ES;!0±v17[11TlFItR
<br />24*. (Sig.of.re end Title) B11-
<br />AND (PHYSICIAN, CORONER S PHYSIC
<br />CD
<br />b.23.
<br />IMTRAR
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />1 QC&& / -
<br />ig-I-)
<br />#!'L1=DIATE
<br />266. 0? -;
<br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), ?Q, AND (c)) ; Interval 1setwosn"set-sidseth
<br />PART
<br />r
<br />^UE TO, ON AS AQ�SEQUENCE OF: InNne1 b•tw••o "so ...A death
<br />DUE TO, OR AS A CONSEQUENCE OF: Ift-I 6.nv*- -W ..d d•eth
<br />Is)-
<br />OTHER SIGNIFICANT CONDIT1O#4S - Conslitioos-ftils.6.9 to death b.0 -smietod
<br />PART Ill. IF FEMALE. WAS THERE A
<br />=Y WAS
<br />AS CASE REVERSED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />120.
<br />r- >_
<br />Yes 0 No ❑
<br />(Sp-gy Y. - cn))
<br />29.
<br />Y, Yr.)
<br />HOUR 01 (JURY DESCRIIE
<br />NOW INJURY OCCURRED
<br />OR LANDING INVESTIGATION. (SP-iy)
<br />(1)
<br />It.
<br />30c. m 30d.
<br />INJURY AT WON
<br />PLACE OF INJURY- At he-. I-, n..l. fmq",
<br />LOCATION STREET OR R.F.D. No. CITY 01 TOWN STATE
<br />(SP-by Yet W ".I
<br />L
<br />1K
<br />200007254
<br />30.
<br />Cn
<br />Cn
<br />ca
<br />Cn
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE KWASKALSTATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TQ - A,'iTVE'COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STM.- A K'.0 -HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE
<br />VITAL RECORDS.
<br />0000 72 54
<br />DATE OF ISSUANCE
<br />06 STANI, �D 1RECTOR
<br />AUG
<br />4
<br />LINCOLN, NEBRASKA BUREAU ..t.STATISTICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />CD
<br />0
<br />MIDW I LAST
<br />SEX
<br />(Mo.. Day. Yr.)
<br />Charles Boyce King
<br />12.Male
<br />3.JUlY 18, 1985
<br />"CE - (e.g., White, Black, American
<br />(e.g., Italian, Mexican' AGE
<br />-Last ti,*Av
<br />L_UNDER I YEAR I
<br />UNDER I DAY
<br />I DATE OF BIRTH (Mo., Day, Yr.)
<br />mos.
<br />MINS-
<br />wic , •k.) (Specify)
<br />JORIGIN/DESCENT
<br />Gorman, &k.) (Specify) (Yr$)
<br />41 White
<br />5. American Q
<br />45
<br />1".
<br />May 31, 1940
<br />CFFT AND STATE OF IHUH (IF not in U.S.A..
<br />4
<br />CMU" Or Wwky-COUNTIRPMA
<br />NEVER MARRIED,
<br />OF SPOUSE (N wife, give maiden name)
<br />i[
<br />0. DIVORCED (Specify)
<br />Knoxville, Tennessee '
<br />9. U.S.A.
<br />jo�!�WICEP,
<br />a
<br />io. Married
<br />Susan A. Sorensen
<br />a
<br />SOCIAL SECURITY HUMBER
<br />SUAL OCCUPATION (Give kind of work done dvring most ND
<br />gorensen
<br />OF BUSINE$S ORfrIaSTRY
<br />COUNTY OF DEATH
<br />of working life, even if retired)
<br />113a. 113b.
<br />s 0 y
<br />114a.
<br />12.506-46-0173
<br />Foreman
<br />ShQp
<br />Hall
<br />CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />- In es r,
<br />K
<br />(Specify Yes or No)
<br />give shee and number)
<br />Ov•ti•fleme, . I.Poti..v (Specify)
<br />i4b. Grand Island
<br />i4c. Yes
<br />14d.St- Francis Medical Center )4..
<br />Emer. Room
<br />SVENCE-STATE COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />I NSIDf CITY LIMITS
<br />,so. Nebraska 1i5b. Hall
<br />,Sc. Grand Island
<br />it". 1706 N. Taylor
<br />I (spssci To ' or No)
<br />So. es
<br />FATHER-NAME FIRST MIDDLE LAST
<br />MOTHER -MAIDEN NAME FIRST MIDDLE LAST
<br />V11
<br />117,
<br />Charles Henry, King
<br />Mary Margaret King
<br />WAS DECEASED MR IN U.S, ARMED FORCEP
<br />INPOW"NT - NAME - RELATIONSHIP - MAILIV40 ADDRESS JSTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIM
<br />(Vs% ... . took) I (it yet, gi�* ", and dafts of -ke)
<br />Dusan A. King-Wife-1706 N. Taylor-Grand Island, NE.688(
<br />to Yes B-31-59/4-30-62
<br />110-&AL, Cremation, Removall
<br />DATE
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION cl TY 01 TOWN STATE
<br />July 22 1985
<br />,
<br />ne, Burial
<br />20b.
<br />2oc. Westlawn Memorial Park
<br />Grand Island, NE.
<br />["A 51GNAT RE U SE N
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />/
<br />fel-Butler-Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />21 12
<br />DA/f
<br />DATE SIGNED (Mo. Day, Yr.)
<br />HOUR OF DEATH
<br />fir
<br />24a. 124b
<br />M
<br />jm5m W 6UT14
<br />dy'- ZF
<br />I
<br />PRONOUNCED DEAD PRONOUNCED
<br />Y-r.j
<br />DEAD (Hour)
<br />23b. 23c. M
<br />VtZ
<br />24.. 24d.
<br />M
<br />To the best .1 y k-1 IPF ti"��79 e.Ad1ZNh&
<br />:�,,
<br />On Is. basis of ...inesen o. iz=. opinion siseth occ-d of
<br />•
<br />t.
<br />cm,*0 sftftd.
<br />•
<br />the It", date and Place end dws, I. I=
<br />its) M
<br />4 r, L
<br />1=R_ES;!0±v17[11TlFItR
<br />24*. (Sig.of.re end Title) B11-
<br />AND (PHYSICIAN, CORONER S PHYSIC
<br />J.J. Cannella M.D. 729 N. Custer, Grand Island, NE. 68801
<br />b.23.
<br />IMTRAR
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />1 QC&& / -
<br />ig-I-)
<br />#!'L1=DIATE
<br />266. 0? -;
<br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), ?Q, AND (c)) ; Interval 1setwosn"set-sidseth
<br />PART
<br />^UE TO, ON AS AQ�SEQUENCE OF: InNne1 b•tw••o "so ...A death
<br />DUE TO, OR AS A CONSEQUENCE OF: Ift-I 6.nv*- -W ..d d•eth
<br />Is)-
<br />OTHER SIGNIFICANT CONDIT1O#4S - Conslitioos-ftils.6.9 to death b.0 -smietod
<br />PART Ill. IF FEMALE. WAS THERE A
<br />=Y WAS
<br />AS CASE REVERSED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />120.
<br />EXAMINER 01 qp"111
<br />Yes 0 No ❑
<br />(Sp-gy Y. - cn))
<br />29.
<br />Y, Yr.)
<br />HOUR 01 (JURY DESCRIIE
<br />NOW INJURY OCCURRED
<br />OR LANDING INVESTIGATION. (SP-iy)
<br />It.
<br />30c. m 30d.
<br />INJURY AT WON
<br />PLACE OF INJURY- At he-. I-, n..l. fmq",
<br />LOCATION STREET OR R.F.D. No. CITY 01 TOWN STATE
<br />(SP-by Yet W ".I
<br />L
<br />office bilstg, @Is. (Sp•ckly)
<br />3%.
<br />30.
<br />I
<br />�_
<br />c
<br />�7
<br />
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