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<br />FIRST
<br />Clarence -
<br />.Lt, Ataer(caw ORIOIN1DE4 ENT(Lg.. It° iaa• M
<br />Gorman, etb.) (Sf eci(y)
<br />5 American
<br />Lit Of.WTllt. ST*TISTICS
<br />'DEA
<br />1 . 1 Tr
<br />RAC — (e.g.. UtiR • $
<br />I ndia A t e dP1
<br />OF I
<br />k1t1
<br />D (Specify)
<br />SEE, INSTRUCTION
<br />MANUAL
<br />PI ac
<br />NSC
<br />Work. 3 .
<br />UC
<br />Reject
<br />:A.
<br />B
<br />I— .0<
<br />I— D. it
<br />Ln Pis
<br />0 E
<br />Part II
<br />TMV
<br />Census Tract No
<br />RAY. 112 DVS-2 0204/-000
<br />DECEDENT l
<br />CITY A
<br />acne coot*
<br />& oza t
<br />14b.
<br />RESIDENCE - .STATE
<br />i st ebraska
<br />16
<br />A E —NAME
<br />Clarence
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Dm. no or eak1. ' IN gist war and date of service)
<br />18. Yes I orean w ar
<br />BURIAL, Cremation, Removal DATE
<br />2 0
<br />2D,: Burial 6.10/10/1986
<br />EMBAL SIGNATURE S U EN L s� NO.
<br />( 4sGt_ d fJ L1i.
<br />21.
<br />Et)
<br />PART
<br />II
<br />DATE OF ATH (Mo.. Day, Yr.)
<br />THEU
<br />INJURY AT WORK
<br />(ipordy Yet ro Ha/
<br />301.
<br />TN ( t not in U.S.A.,
<br />Nebraska
<br />COUNTY
<br />15b. Hall
<br />ACCIDENT, SUICIDE. HOMICIDE, tANDET.,
<br />OR PENDING NHVESTIGATION. (Specify)
<br />30f.
<br />MIDDLE
<br />11144 148
<br />MIDDLE
<br />USA
<br />I CIAlSEC1iRET1INLFMIER USUAL OCCUPAT ON (Gin, kind al wayS don,
<br />12505 - 32 - 7577 , ; °Reg even lie manager
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPIT
<br />(Spaci Yeror we dr
<br />OmaHa Uni
<br />(
<br />( C C t r, / C f9 /Y
<br />DUE TO,. 04 AS A CONSEQUENCE OF
<br />f c ,40 P/I l rt
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />/ e.t G L+ // G r t.L k r.1
<br />ICANT CON ?IONS - Conditions carttribvtiog to death bet not related
<br />DATE OF INJURY (Me., Day, Ys.)
<br />30b.
<br />PLACE Or NJURY - At bane, lore, strati', factory.
<br />tali* building, etc. (Specify)
<br />HOUR OE
<br />NEVER
<br />D . Oly
<br />rri
<br />t
<br />t IND OF BUSINESS OR INDUSTR
<br />R ropane Gas
<br />oa OTHER INSTITUTION - Nance (If not in •i
<br />s : a tenter '
<br />CITY. TOWN ORLOCATION STREET AND NUMBER
<br />19 ,Grand Island , isd. 818 W.10th
<br />LAST MOTHER — MAIDEN NAME FIRST - MIDDLE
<br />Osborn Tr Minnie
<br />INFORMANT NAME — RELATIONSHIP MAILING ADDRESS ST TMILFD. NO.. tTY R O" N. STATE. ZIP)
<br />,,Patricia Osborn,wife, 818 Wbfh, 6 8 Island
<br />CEMETERY OR CREMATORY— NAME LOCATION CITY OR TOWN STATE
<br />20c. Grand Island City Cem.QOd, Grand Island, Nebr.
<br />FUNERAL HOME — NAME AND ADDRESS (STREET 0'11.1.0 NO., CITY OR TOWN STATE. ZIP)
<br />Nebr. 6881
<br />2 L vingston- Sondermann, 505 W. Koenig, Gran Is1
<br />DATE SIGNED(Ma.'Day, Yr.) HOUR Of DEATH
<br />� / [ 2 W
<br />23a. / iI / ' Lf �i+'
<br />urC
<br />DATE SIGNED (Mo.. Day, Yr.) 24a.
<br />.) ) / HOUR OF 1 DEATH it PRONOUNCED DEAD
<br />236. / ) — 7' ()h ,23c. J
<br />T N g (Mo., Yr.)
<br />u"r�`ie? 1: 24c. 5d.. M
<br />To the bee et me isewisdge, death occurred at Me tiros, data and plats 'doe to the 241 On the basis e( awnr'rnotiea amuse inatupation, in ley opinion death occurred at
<br />ceuse(s) Mated. ° : L , a the ripe. dote and ;ear end des M Ma caotaWMebd.
<br />234.(Sipwelera ate Title) iL.r7 f �' "' r ' ° u M a.(Signeture and Tide)
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />A �1 A !
<br />25. f. / n [ P Mae, / � 1T l/*; Hd 1 d
<br />°j Lro.) p 0 (I et, NJ
<br />REGISTRAR t ' DATE RECEIVED BY REGISTRAR (Mo., Day, Yr)
<br />/yam cam'
<br />26a.(YpaetureJ10' �
<br />TT. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNf FOR (a). (6) AND (c))
<br />PART
<br />NANCY IN THE EAST 3 MONTHS? `AUTOf
<br />LE, WAS THERE A (sp(Specify y Ter Sr Net
<br />28. y'Er J
<br />UsY DESCRIBE HOW INJURY OCCURRED
<br />M
<br />SOCATION ..
<br />304
<br />Yes 0 No ❑
<br />30d
<br />DA
<br />26b
<br />Patrici
<br />:
<br />STREET OR R.F.D. Ns.
<br />ea
<br />Yr.)
<br />Day, Yr.)
<br />r une 18, 1929
<br />rq v,,r,u+d�n:eoatel ,
<br />ohms on
<br />114
<br />uglas
<br />Y. fF iIOSP.- 0*11tST. Indicate DOA,
<br />Outpat:satlbeer. L. Inpatient (Speoity)
<br />141, Inpatient
<br />Robertson
<br />INSIDE CITY LIMITS
<br />(SperifoYm, r No)
<br />Ise,
<br />LAST
<br />ED DEAD (Hour)
<br />s Iatervol ens., end death
<br />I between cruet and death .
<br />d4y
<br />ei.r,el between onset end death
<br />`WAS CASE - REFERRED TO MEDICAL
<br />EXAMINER OR:CORONER
<br />(Speedy Yes or No) A
<br />29. O .
<br />CITY OR TOWN STATE
<br />
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