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1. DECEDENT - NAME FIRST MIDDLE LAST 2
<br />2. SEX 3
<br />3. DATE OF DEATH (Mone Dry, Yowl
<br />4. CITY AND STATE OF BIRTH (M not In U.S.A. name country) e
<br />ea. AGE - LaM Birthday U
<br />UNDER 1 YFAR I
<br />I INDFR 1 DAY 6
<br />6. DATE OF. BIRTH (M net Day, Year)
<br />513 MOS. I DAYS 5
<br />5c. HOURS' MINS.
<br />7, SOCIAL SECURITY NUMBER 8
<br />80- PLACE OF DEATH -
<br />- _. __...._,.._._ _ . _ _.,,• , _ _.. _ . __ __ ,.
<br />HOSPITAL 0 Uppsnt 0 ERlOulpatlem 0 DOA
<br />smut 0
<br />0 Nursing Home Ft Residence 0 Other ISpecIy)
<br />Ob. FACILITY - Name (h not institution, give sheet and ,84nbS) 8
<br />8c. CITY, TOWN OR LOCATION OF DEATH 8
<br />8d INSIDE CRY UNITS B
<br />Be. COUNTY OF DEATH
<br />9s. RESIDENCE - STATE 9
<br />90 COUNTY S
<br />Sc. CITY, TOWN OR LOCATION 9
<br />9d. STREET AND NUMBER (N cIudi g Zip Cod) 9
<br />9a. INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />10. RACE - (a.g, Wmita Shea, American Indian, t
<br />t1. ANCESTRY Ieedallan, M
<br />Memel. German. etc.) 1
<br />12. MARRIED,NEVER MARRIED, 1
<br />15. F
<br />13. NAME OF SPOUSE (NWM, give maIden name)
<br />_ of *wring Ma, .Men rn I er5 (q O'i (
<br />(/ p 1 E
<br />Efem ntwy or Secondary (0-12) I College (1-4 or 5
<br />16. FATHER - NAME FIRST MIDDLE LAST 1
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />- 18. WAS E
<br />EVER IN U.S. ARMED FORCES? 1
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN ZIP) g �]
<br />20a BURIAL. Croma on,RanovaL 2
<br />200. DATE 2
<br />20c. CE M ETER P OR CREMATORY - NAME 2
<br />20d. LOCATION CITY OR TOWN STATE
<br />21. EMBALMER - SIGNATURE & UCENSE NO. ?? /',- 2
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR T�I,a A d ZIPL Island,
<br />OTHER SIGNIFICANT CONDITIONS • Condom. contributing to death but net related PART III IF FEMALE, WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY « ❑ THE PAST MONTHS? (Specify Yeq r N y p CORONER?
<br />It ivr t/ N ` 0
<br />26a. ACCIDENT, SUICIDE. HOMICIDE, UNDET., 280. DATE OF INJURY (Mo.,Day. Yr.) 28c. HOUR OF INJURY 26d. OESC E W INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Specify)
<br />M
<br />26e. INJURY AT WORK 261. PLACE OF INJURY - Al home, farm, feet factory, 26g. LOCATION STREET OR R.D. NO. CITY OR TOWN STATE
<br />(Spscfh Yes or No) office building, ale. (Specr0
<br />27a. DATE OF DEATH (Mo., Day, Yr.) 280- DATE SIGNED (Ma, Day, Yr.) 290. TIME OF DEATH
<br />September 30, 1992
<br />B 270. DATE SIGNED (MO., r.) 27e. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo., Dey, Yr) 28d. PRONOUNCED DEAD (Hour) M
<br />gg September, 3(,1992 7:35 AM 'i*
<br />' 3 M M
<br />2711 To the Oast of my k , d) ppoactbmsd tlJ]ygMNa time, 0-W Macs and due to 1M 28e. On 81s basis of examination artl/p irtveeligetnon, in my opinion death OCGtbrreO M
<br />i ' 8 catbirds) sated. • ! n the ems, date and p lace and d to the cauaels) stated.
<br />I j end Tidel)� v v t'
<br />t Iswmawn and Tins)*
<br />290- 010 TOBACO USE D- COJt 'TO THE D UNKNOWN HAS TISSUE DONATION BEEN CONSIDERED? 380. WA CONSE GRANTED?
<br />❑ YES Q NO
<br />NAME
<br />31. NAME A ADDRESS OF CERTIFIER IPHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or P&Mt) \( /
<br />Dr. Joh Wagoner Jr M.D. 800 Alpha, Grand Island, NE 68803
<br />320- REGISTRAR 320. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />• _rill, ,_ OCT5 1992
<br />PART / Y
<br />■ DUE TO, OR AS A CONSEQUENCE OF:
<br />a
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, FT 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 IS THE LEGAL_ DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCR 131992
<br />LINCOLN, NEB SKA
<br />DUE TO, OR AS A CONSEQUENCE
<br />201805616
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS . 'J
<br />CERTIFICATE OF DEATH \ .`' .
<br />201704941
<br />STANLEY S. COOPER, -;DIRECTOR
<br />BUREAU OF: • STAISTICS
<br />Interval between onset and death
<br />m!WeeW aerrimen rime! a l Math
<br />PART / Y
<br />■ DUE TO, OR AS A CONSEQUENCE OF:
<br />a
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, FT 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 IS THE LEGAL_ DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCR 131992
<br />LINCOLN, NEB SKA
<br />DUE TO, OR AS A CONSEQUENCE
<br />201805616
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS . 'J
<br />CERTIFICATE OF DEATH \ .`' .
<br />201704941
<br />STANLEY S. COOPER, -;DIRECTOR
<br />BUREAU OF: • STAISTICS
<br />Interval between onset and death
<br />m!WeeW aerrimen rime! a l Math
<br />
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