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1. DECEDENT • NAME FIRST MIDDLE LAST
<br />Maxine • Eva Radcliff
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Month, Day, Year)
<br />September 30, 1992
<br />4. CITY AND STATE OF BIRTH (If not in USA, name country)
<br />,.rand Island, Nebraska 1
<br />Se (ARE)• Last Birthday
<br />69
<br />1 Y DAYS
<br />1 A
<br />6. DATE OF BIRTH (Month. Day, Year)
<br />July 12, 1923
<br />6b. MO I
<br />�
<br />Sc. NWHSI
<br />�
<br />7. SOCIAL SECURITY NUMBER
<br />508-18-5469
<br />8a. PLACE OF DEATH
<br />i DTMER
<br />- - -
<br />HOSPITAL: 0 Inpatient 0 ER /OutpatisM 0 DOA
<br />O N Horne §1 Residence 0 Other (Specify)
<br />28a. DATE SIGNED (Mo„ Day, Yr.)
<br />8b. FACILITY • Name (d not institution. give street and number)
<br />`1511; East 7th Street
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />8d. INSIDE CITY UMITS
<br />(Specify Y. or No)
<br />Yes
<br />Be. COUNTY OF DEATH
<br />Hall
<br />- 9a. RESIDENCE - STATE 19b. COUNTY
<br />Nebraska Hall
<br />9c. CITY, TOWN OR LOCATION
<br />Grand Island
<br />90. STREET AND NUMBER (including Zip Cods)
<br />1511; E 7th Street
<br />9e. INSIDE CITY LIMITS
<br />(Specify Yea or No)
<br />Yes
<br />10. RACE - (e.g., White, Black, American Indian,
<br />Mc.) (Specify)
<br />White
<br />11. ANCESTRY (e.g.,tlatian, Mexican, German, etc.)
<br />(Specify)
<br />American 06
<br />12. MARRIED,NEVER MARRIED,
<br />WIDOWED. DIVORCED (Specify)
<br />Married
<br />13. NAME OF SPOUSE (If wife, give maiden name)
<br />Wayne Radcliff
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />of working lib, Ivan proCred) - 1 ,)
<br />t V
<br />Homemaker V
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION ISoecity OnlY hlnbeMyrade conflicted)
<br />^ ( I
<br />Domestic '
<br />Elementary or Secondary (0.12) I College (1-4 or 5 +)
<br />12th 1
<br />. 16. FATHER - NAME FIRST MIDDLE LAST
<br />! _ Arthur - Davis
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Etta - Dixon
<br />' 18. WAS DECEASED
<br />(Yes, no, or unk.)
<br />No
<br />EVER IN U.S. ARMED FORCES?
<br />(a yes, give war and dates of services)
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP(
<br />G ran E I 8T /
<br />Wayne Radcliff 151 l E 7th St., II
<br />206. BURIAL. Cremalion,Renloval,
<br />Donation
<br />Burial
<br />20b. DATE
<br />Oct. 3, 1992
<br />20c. CEMETERY OR CREMATORY - NAME
<br />Grand Island Cemetery
<br />20d. LOCATION CITY OR TOWN STATE
<br />Grand Island, NE
<br />21. EMBALMER - SIGNATURE 8 LICENSE NO.
<br />L
<br />L L . 3 I , ( , ? z _- I L - � J 7
<br />22. FUNERAL HOME - NAME AND ADDRESS - (STREET OR R.F.D. NO., CITY OR T N, STMT ZIP
<br />ran ` I sland,
<br />Apfel- Butler - Geddes, 1123 W 2nd St . , NE 68801
<br />91 ImAFtNAT1{ r LI ICC _ IFNTFR ['WV r1NF r :LIKE
<br />PFR I INF FOR lal 151 ANn .1 I Interval hwtwaan nnent And death
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to death but not related
<br />PART
<br />II
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST MONTHS?
<br />n Y es ❑ No
<br />24. AUTOPSY
<br />(Specify Yeso
<br />r !✓
<br />25. WAS CASE REFERRED TO MEDICAL
<br />E XAMINER OR CORONER?
<br />( Yea DLO IN
<br />26a. ACCIDENT, SUICIDE. HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION (Specify)
<br />28b. DATE OF INJURY (8O.,Day, Yr.)
<br />28c. HOUR OF INJURY
<br />M
<br />26d. DESCRIBE OW INJURY OCCURRED
<br />26e. INJURY AT WORK
<br />(Specify Yes or No)
<br />261. PLACE OF INJURY - At home, farm, street factory,
<br />office budding, etc. (Specify)
<br />269. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />27a DATE OF DEATH (Mo.. Day, Yr.)
<br />September 30, 1992
<br />A1$4O
<br />13NNOUV AIN1100 n
<br />NV OISAM SIGNON00
<br />00110 07 01
<br />28a. DATE SIGNED (Mo„ Day, Yr.)
<br />28b. TIME OF DEATH
<br />L
<br />gg
<br />E$
<br />+i
<br />1
<br />270. DATE SIGNED (Mo., De r
<br />September 30,1992
<br />27c. TIME OF DEATH
<br />7:35 AM
<br />M
<br />28c. PRONOUNCED DEAD (Mo., Day. Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />M
<br />27d. To the best of my knowledge death occurred at jpe time, dati/and place and due to Me
<br />)
<br />cause(/) staled. - 'r A� 1�� �% / 1 , / I/ r
<br />T
<br />1 .)C,
<br />28e. On the basis of examination and or investigat on, in my opinion death occurred at
<br />0. the time, date and place and due to the cause(s) stated.
<br />(Signature and Title) 0
<br />(Signature and Title C - ,•
<br />29� TOBACCO USE CONTRIBUT.TO THE DEATH?
<br />/YES 1. o-N 0 UNKNOWN
<br />3091 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />, 0 YES � NO
<br />300. WA CONSENT GRANTED?
<br />❑YES ❑ NO
<br />31. NAME AND OF CERTIFIER (PHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr. Joh Wagoner /Jr M.D. 800 Alpha, Grand Island, NE 68803
<br />32a. REGISTRAR ,/ /
<br />' "a
<br />320. DATE FILED BY 5 REGISTRAR (Mo., Day, Yr.)
<br />1992
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH TO TIE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCT 1 3 1q2
<br />LINCOLN, NEB SKA
<br />PART ( d
<br />TO. J OR A F:
<br />DUE 0 AS CONSEQUENCE 0
<br />7
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ;
<br />I Interval between onset and death
<br />201704941
<br />STANLEY S. COOPER, DIRECTOR
<br />BUREAU OF VITAL STATISTICS
<br />(
<br />n■aet nnr1 Aea_/h
<br />
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