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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Arthur Douglas Cone <br />2. SEX <br />Male <br />3 DATE OF DEATH (Month. Day. Year) <br />February 25, 1998 <br />4. CITY AND STATE OF BIRTH (If not in USA.. name country) <br />Berwyn, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.' 73 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day Year) <br />July 13, 1924 <br />Sb. MOS. 1 DAYS <br />I <br />Sc. HOURS' MINS <br />7. SOCIAL SECURTIY NUMBER <br />505-22-7283 <br />8a. PLACE OF DEATH <br />HOSPITAL: Fy Inpatient OTHER Nursing Home <br />fl ER Outpatient Residence <br />[] DOA Other (Specrryi <br />8b. FACILITY - Name /N not insetulron, give street and number) <br />St. Francis Medical Center <br />28a. DATE SIGNED (Mo.. Day Yr.) <br />4c. CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />86 INSIDE CITY LIMITS <br />1 Yes 4 No <br />8e. COUNTY OF DEATH <br />I Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY, TOWN OR LOCATION <br />Grand Island <br />911. STREET AND NUMBER 'Including Zip Code) <br />1812 West 11th Street, 68803 <br />9e. INSIDE CITY LIMITS <br />Yes ka No <br />10. RACE W � �(e.g ., ., White. Black. American Indian. <br />HO' <br />11. ANCESTRY (e.g.. Kaftan. Mexican. Getman, etc) <br />5Viii <br />12. la MARRIED ❑ WIDOWED <br />❑ NEVER ❑ DIVORCED <br />MARRIED <br />13. NAME OF SPOUSE (0 wise give maiden name) <br />Alvera E. Wagner <br />14a. USUAL OCCUPATION (Give kind o7 work dare during most 95y <br />i essman nreered' <br />146. KIND OF BUSINESS INDUSTRY <br />Farm Machinery 5 „ ^ <br />15. 5. EDUCATION (Specify only highest grade completed) <br />Elemeyagr or Secondary (0 -12) College I1 -4 or 5 ■1 <br />1 � <br />16. FATHER - NAME FIRST MIDDLE LAST <br />Arthur Douglas Cone <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Ethel Marsh <br />18. WAS DECEASED <br />IYeg-f or unk.) <br />1j�rl <br />EVER IN U.S. ARMED FORCES? <br />I (If yes. gyve war and dates of services) <br />19a. INFORMANT - NAME <br />Alvera E. Cone <br />OTHER SIGNIFICANT CONDITIONS! Conditions contributing a the death but not related <br />PART JL� _ y p �} ��(n� <br />II t"jl �'/ � �" � " 1 �-I y� - 'L��_ a. .i <br />ART IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10 -54) Yes n No [1 <br />24 AUTOPSY <br />Yes No xi <br />xi <br />25. WAS EASE REFE4RE�O MEDICAL <br />EXA OR CORONER <br />��yy <br />Yes No <br />26a. <br />le Accident ■ Undetermined <br />E Suoade 0 Pending <br />. Homicide Investigation <br />26b. DATE OF INJURY (Mo. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />264. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes No <br />❑ ❑ <br />At home, farm. street. factory <br />26f. PLACE ;60 bu ng IN . JU etc. RY - (SpeoVy) <br />08ddi <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />To be Completed by <br />Abending PHYSICIAN <br />ONLY <br />27a. DATE OF DEATH (MO.. Day Yr) <br />February 25, 1998 <br />a> <br />U cr <br />cr <br />i Q T <br />r.' .1 <br />° w ° <br />° <br />28a. DATE SIGNED (Mo.. Day Yr.) <br />28b. TIME OF DEATH <br />M <br />28c. PRONOUNCED DEAD /Mo.. Day. Yr) <br />284. PRONOUNCED DEAD /Hour) <br />27b. DATE SIGNED (Mo.. Day Yr) <br />February 26, 1998 <br />27c. TIME OF DEATH <br />5:18 p. <br />28e. On the basis of examination and or Investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. <br />'(Signature and Title) ► <br />27d. To the best of my knowledge. death urred at the ti date and place and due to the <br />ii. cause(s) stated. • {/'� J/ <br />(S)gnature and Title) ► � p � ' �^" <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />YES [) NO UNKNOWN <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />NO <br />YES 1Q7 <br />30. WAS CONSENT GRANTED? <br />�-}� <br />YES I NO <br />195. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( <br />1812 West 11th Street, Grand Island, Nebraska 68803 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO <br />�� �,� <br />/ <br />2?a t'UNERAL H,ME - NAM <br />Apfel - Butler- Geddes Funeral Home <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE, ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />23. IMMEDIATE CAUSE <br />PART <br />i I <br />(al <br />201801561 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN- SERVICES <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON PILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICHIS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - <br />DATE OF ISSUANCE <br />MAR 6 1998 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND :SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />21a METHOD OF DISPOSITION 1 <br />® Burial El Removal <br />E l Cremation El Donation <br />/t1 <br />DUE TO, OR AS A CONSEQUENCE OF <br />V <br />(ENTER ONLY ONE CAUSE PER LINE FOR 10. )b). AND (0) <br />DUE TO, OR AS A CaNSE E OF <br />Ic) <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or P9irp <br />Dr. Daniel R. Cronk, 908 N. Howard Ave., Grind Island, Nebraska 68803 <br />32a. REGISTRAR <br />• <br />S1 ANLEY S COOPER <br />ASSISTANT STATE REGISTRAR <br />HEALTH AND HUMAN .SERVICES SYSTEM <br />21b. DATE <br />02/28/1998 <br />21d. CEMETERY OR CREMATORY LOCATION <br />Grand Island, Nebraska <br />21c. CEMETERY OR CREMATORY . NAME <br />Grand Island City Cemetery <br />CITY OR TOWN STATE <br />Interval) between onset and death <br />Interval between onseT and death <br />Interval between and death <br />d <br />32b. DATE FILED BY REGISTRAR (419� <br />