|
STATE OF NEBRASKA
<br />WHEN : THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />8/25/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT - NAME
<br />THOMAS
<br />1 4. CITY AND S T A T E OF SiRTH (A' ndt in LISA. mama co 0yi
<br />Grand Island,Nebraska
<br />7 . S000d. sECURITY NUMBER
<br />506 -20 -3882
<br />SR. FACWITY • 1,--aa (e nor irtaaar0on, g io abet and numaerl
<br />! bn NORP�
<br />9a. RE$ OSI CE -STATE +.no. COUNTY
<br />N
<br />14a. =A. OCCUPAr1ON Ova kind of 'f work done during roost
<br />d 91rnyLYic avmareend)
<br />20a. BURIAL, C»mMJOn,Ramoral, 20o DA
<br />uW
<br />Drort
<br />Burial
<br />•::$1G ' URE & :_ SE NO.
<br />2614
<br />29 T 1 My
<br />tat
<br />of
<br />DUE TO, OR AS 71 OF: r`
<br />DUE TO, OR, AS A CONSFCHIENCE OF
<br />►g l
<br />PART O R SIGNIFICANT CONDITi0N
<br />ZSa. ACCIDEN;<. SUICIDE, HOMO DE UNDET.
<br />OR:PENDIONIIMEST*GATION ( ,
<br />)
<br />c
<br />INJURY AT WORK
<br />(Spstify Vi* a No)
<br />2Ta : DATE Of DEATH (Mo., Day, Yr.)
<br />REt3ISTRAk1.
<br />FIRST
<br />.February 2, 1993
<br />. To 6ii of
<br />r#uiNJj sand.
<br />C l m
<br />ab /WNW
<br />e.i TOBACCO'USE TO
<br />I ` YES ❑ NO
<br />Ea. PLACE OF
<br />S3
<br />FIRST MIDDLE LAST
<br />STATE OF NEBRASKA -- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATIST CS
<br />CERTIFICATE OF DEEAT H 1 ` 1 i r`
<br />x
<br />I Male s e
<br />MIDDLE LAST
<br />Le
<br />O' MALLEY
<br />DEATH
<br />HOSPITAL: IApatreM 0 ER /OulpateM `7 DOA
<br />Q Wrong 0 nng Hues ❑ R u
<br />aaidance O Oth ,OPer•rfyl
<br />ac CITY, TOWN OR LOCATION OF DEATH
<br />Omaha
<br />CRY. TOWN OR L
<br />Bla -
<br />10. RACE - (a.g, WNW, ek American Indian, 11. ANCESTRY (e.g.,Nakan, Memean, Gorman, sr.)
<br />WD } {Spa iffl (Specify!
<br />White T F . <, IN
<br />Ib KIND OF BUSINESS INDUSTRY
<br />Michael H. O'Malley
<br />. WASARMED >DECEASED. EVER IN U.S. ARMED FORCES? 19. INFORMANT - NAME -
<br />25D. DATE OF INJURY (Mo.Day. Yr.) 26o N - R OF NJURY
<br />2Sf. PLACE OF INJURY - At nome. farm, atreal ta:>'oy,
<br />Dike building. at. (SwciH.i
<br />STANLE .COOPER
<br />ASSISTA T STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />93 .0i 778
<br />DSTE OF DEATH /Month. Day; Yaw)
<br />February 2,1993
<br />1 5a_ AG£ • UM ButloCay I Ilts0PA 7 VAR UNDFR 1 DAY SMITH Modal, DATE OF SMI Modal, Dty. Y � , � f MOS I DAYS 5c. HOURS MINS. 5
<br />November 24,1927
<br />Loan td. INSIDE CRY U Sc:: .COUNTY. OF DEATH
<br />IS oty Yea or No)
<br />�
<br />9d. STREET AND NU R S htaktdng ZW CA0 1 TT 8 � 9i 6 S * CITY L*91'S
<br />( Spcy Yea ar AM/
<br />9t9 •
<br />12: MARA/ED.NEVER MARRIED.
<br />WIDOWED. DIVORCED (Speedy)
<br />13. NAME OF SPOUSE rd a ila, gwa: maANN AM*
<br />FATHER NAME
<br />17. MOTHER - MAIDEN NAME
<br />OR R_F.D. NO.. C(iX:OR TOWN, STATE M.
<br />(Yea, rw, u unk; (n yea. gnus war and dues of aen'icea) Grand Island, Ne . ..
<br />YPq 1 Kansan Vi 1 6/46 - /2. /40 Patri ri a f)' Mall ev 1 091 W n rri
<br />DIATE.CAU
<br />20c,: CEMETERY; OR CREMATORY - NAME ' 200. LOCATION CITY OR TOWN
<br />,1993 Grand Island Cemetery Grand Island,Ne
<br />JFebr 6
<br />22 FUNERAL HOME - NAME AND ADDRESS (STREET OR RFD NO C7TY OR TWIN, STATE; )
<br />ivin : .ton sond.errnan D U D w. I o Pn Nebraska
<br />ONLY CAUSE PER LINE -FOR (a). (b;. AND (di/
<br />contributing 10 death but mote PART III IF FEMALE, WAS THERE A
<br />PREGNANCY 14 THE PAST 3 MONTHS?
<br />Yes O No
<br />•. DATE SIGN • 1
<br />27c. TIME OF DEATH
<br />265. LCCATtON
<br />AILING ADDRESS
<br />5. FM IS (Swr
<br />Elementary or Secondary 10- 121 .., 1 .
<br />FIRST •
<br />Katherine Schulte
<br />(STREET
<br />1260. DESCRIBE HOW INJURY OCCURRED
<br />STREET OR 0.F.0. NO.
<br />PRONOUNCED DEAD (AU.. Aey Yr/
<br />YfR�[
<br />1 32b
<br />MIDDLE LAST
<br />23a DATE SIGNED (Mo.. Day. Yr/ BlItt FIE£?F.DEATH
<br />31. NAME. AND ACORESS OF CERTIFIER (PP. Y SICAN. CORONER'S PHYSICAN OR COUNTY ATTORNEY)., (Tjry'! or Prrntj
<br />Timothy K, Kingston ND 270N Doctors Building Omaha NE 16$13V
<br />I M vaf o -NMaan ... . am::
<br />CITY OR TOWN STATE
<br />No PRONOUNCED :COO OO !flaw)
<br />2Se On the Las* of aamnaon and cc awpegfapn, in::rW contort O NI maned at
<br />the lion. r.M0 a615 placa and de lo tM camels) (Wad. ..
<br />saw and Ms
<br />RGAN OR TISSUE DONATION BEEN CONS(. - ' ? WAS CONSENT GRANTED?
<br />D YES C: YES
<br />DATE F1LE:t BY RE0.ST ,'OFD. Day tr j
<br />FEB 919
<br />$7ATE
<br />24. AUTOPSY 2s, WAS CASE TO WICAL
<br />(Sc yaay Yea or NW or.ANNER OR C00R0fIE ".%
<br />Mod& Yager MN
<br />Cn
<br />
|