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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 />9/28/2018
<br />LINCOLN, NEBRASKA
<br />7 RUSSELL FOSLER
<br />2 018 Q 6 6 INTERIMTRAP
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />ik
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />79
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />Alonzo
<br />LniNtence -1:4.4.k..2.
<br />SEX
<br />I;ULLe
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />3 Apni-C 17, 1979
<br />.6Carugo
<br />1.
<br />RACE-(e.g., White, Black. American
<br />ORIGIN/DESCENT (e.g.,Italian, M•aicars,
<br />AGE-Loneagsdoy
<br />UNDER 1 YEAR UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr,)
<br />Indian, etc.) (Specify)` �.
<br />4. w to
<br />German, etc.) (Specify) Q
<br />13. S Go ifs Cil. 5it,i.. )/L : •
<br />(Yrs.) - y_,
<br />l5
<br />MOS. : DAYS 1 HOURS : MINS.
<br />6b. I6c.
<br />17. L/ 21, 1L;%03
<br />_.
<br />aft AND STATE OF BIRTH (0 not in U.S.A.,
<br />name country)
<br />B. 0o nto , R eG�w.4 ku.
<br />ICITIZEN (,”: WHAT COUNTRY
<br />9 1 . J e A.
<br />"AARRiED, NEVER MAitR)ED, i NAME OF SPOUSE (If wife, give maiden nome)
<br />WIDOWEQ, 9IVORC�E99(Specify)
<br />10. 1.04.X1-0tes"E:(1 11.
<br />SOCIAL SECURITY NUMBER
<br />C `1 �. q p (�
<br />12. 506-28-1886
<br />USUAL OCCUPAT ON (Give kind of weer* done Bering most
<br />of working life, even if retired) �T 'J C
<br />13a. 7u)un.t.Ilg !'
<br />KIND OF BUSINESS OR INDUSTRY
<br />136 11. ICA J e
<br />COUNTY OF DEATH
<br />�1�,
<br />140.
<br />CITY, TOWN OR LOCATION OF DEATH I INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />14b. 114c. no
<br />HOSPITAL OR OTHER INSTITUTION - Name (11 not in either,
<br />give street pnd number)
<br />14d. ho)it.e - Ai 1
<br />IF HOSP. OR INST bdicate DOA,
<br />Outpatient/Emer Rm., InpotiMt (Specify)
<br />14e.
<br />RESIDENCE -STATE
<br />k(LME
<br />COUNTY
<br />ha-a,MIDDLE
<br />CITY, TOWN OR LOCATION
<br />lk Ca��LAST
<br />STREET AND NUMBER
<br />202
<br />INSIDE CITY LIMITS
<br />(Speci Yes or No)
<br />L.
<br />15e "'
<br />FATHER- HALL.
<br />16 rA.0
<br />T56
<br />ei.e - f.
<br />MOTHER -MAIDENS AME RST�ax
<br />MIDDLE T
<br />17. l iL) a.e.t -lie%I vwe
<br />hs
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />:Yes. no or sink)(If yes. gi•e •.or and dotes of service)
<br />18-: W
<br />INFORMANT- NAME -RELATIONSHIP -MAILING ADDRESS (STREET OR R.f.D. NO., CIT, OR TOWN, STATE. ZIP)
<br />r O n
<br />19. /L) rilluuG X4...17-1..-4on- k.k 1 Box 165, Co-iiw, tie 00624
<br />.I
<br />BIR
<br />BURIAL, CremQtion, +Removal
<br />20a. BL JJ..
<br />DATE
<br />lob. 4/20/79
<br />CEMETERY OR CREMATO,R,Y-NAME LOCATION I } CITY OR TOWNf: STATE
<br />20c. She lltorL I20d. She.L .on, flthit 4k
<br />EMBALMER
<br />-SIGNATURE LICENSE NO. I
<br />coy
<br />l
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO.. CITY 02 TOWN. STATE. ZIP)
<br />n. rtQe.,l. fu.ne Lc -L hone, i'Jood ;�-i_ue t, he-lr2 - ka. 68883
<br />.21.
<br />s< mu :
<br />of ge. Beeth un of •time, date and plop and dire tee rhe
<br />o benmy *novrled0
<br />ceuse(11 gated
<br />23a. (Sipneture end Tali.) •
<br />To b.: ComptH.d by
<br />CORONER'S PHYSICIAN,
<br />:I or COUNTY ATTORNEY
<br />only
<br />On the basic of examination and/or investigation, in my opion death occurred of
<br />sty time. data and place and due to tie causes) stated
<br />24a. (Slgnetwe end Tine) K/ lidt
<br />a.t16
<br />DATE SIGNED (Mo. Day. Yr.)
<br />246. 5-8- 79
<br />H U OF ATH
<br />24c. 9:00 A. / M
<br />to
<br />U c
<br />DATE SIGNED (Mo., Doy, Tr.)
<br />236.
<br />HOUR OF DEATH
<br />23c. M
<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
<br />24d. 4-3.7-79
<br />PRONOUNCED DEAD (Hour)
<br />24e 6:00 P.
<br />v
<br />3.
<br />1.4
<br />DATE OF DEATH (Min Doy, Yr.)
<br />23d.
<br />AME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S
<br />PHYSICIAN OR COUNTY
<br />Ai
<br />25 W. E. Lawrey, Sgt. County -City Building
<br />I► REGISTRAR
<br />yy
<br />26a.(Signature/PP'
<br />Grand Island• NE 68801
<br />DATE RECEIVED BY REGISTRAR (Mc., Day, Yr )'
<br />i
<br />266. 2
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (o). (b), AND (c))
<br />PART
<br />,, coronary occlusion
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing •o death but not
<br />It
<br />elated
<br />PART In. If FEMALE, WAS THERE A AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONIHS? 1 (Specify Ty or No/
<br />VL`
<br />Yes .. No , . I 28
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDET,
<br />OR PENDING INVESTIGATION (Specify)
<br />300.
<br />I3
<br />a INJURY AT o1 N
<br />ISDeci/y Yes Ne)
<br />DATE OF INJURY W. . Dor, Y, 1
<br />HOUR OF INJURY
<br />30b. 30c.
<br />0e.
<br />PLACE 01 INJURY- AI home. farm, street, lostory.
<br />office building, etc (Specify)
<br />304.
<br />DESCRIBE HOw IN. uR, OCCURRED
<br />M 2.0d.
<br />VOCATION STREET OR RFD. No
<br />300.
<br />Interval between onset and deoth
<br />Interval bei.een onset and deo*
<br />. Intervol betieen onset oral ceoth Cji
<br />WAS CASE REFERRED TO MECICxI C.
<br />EXAMINER OR CORONER
<br />I(Specify Yes w Na'
<br />29 Y e I I
<br />C)TYOR TOWN (STATE
<br />1
<br />0
<br />
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