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<br />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 DEPOIrFolfr
<br />fDS
<br />DATE OF ISSUANCE
<br />8/25/2017
<br />LINCOLN, NEBRASKA
<br />201707738
<br />STANLE%p. COOPER
<br />ASSISTAWT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NIEBi'rASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL'STATFSTICS
<br />CERTIFICATE OF DEATH
<br />93.0 778
<br />p. DECEDENT - NAME FIRST MIDDLE LAST
<br />THOMAS L. O'MALLEY
<br />2, SEX 13 DATE OF DEATH /Week Day, Yew)
<br />Male I February 2,1993
<br />4 CITY AND STATE OF BIRTH (e not in USA, nine country) • Ia. AGE • La3t 8 rE4ay
<br />rail-)SQ
<br />Grand Island,Nebraska 65
<br />UNDFP 1 YEAR 1 UNDER 1 DAY CATE OF BIRTH (loner, Day. Yawl
<br />18.
<br />F MOS. ;DAYS Sc. NOURS' MINS.
<br />i November 24 1927
<br />7. SOCIAL SECURITY NUMBER
<br />506-20-3882
<br />ISa PLACE OF DEATH HOSPITAL:'. Inoahent " O ER; Outc.acenl i 7 DOA
<br />1 o Wrong Home 0 Reada ce 0 Durr (Specify)
<br />__Q,THER
<br />W. FACILITY . 147;1 (N not insandion, gore aveW and nun an
<br />!
<br />•°,121r1AO F To.
<br />ix an,. TOWN ON LOCATION OF DEATH
<br />Omaha
<br />Ed. INSIDE CRY LIMITS
<br />(SdacIy Yep or No)
<br />Be. COUNTY OF DEATH
<br />licI T
<br />St RESID'c!vICE -STATE
<br />N-. ,.
<br />C .t N
<br />90 COUNTY
<br />•.
<br />Sc. CRY, TOWN OR LOCATION
<br />.•e .•II
<br />MBEp Snclraeg Zip -1 19ee.
<br />90. STREET AND NU R r
<br />I e
<br />WSIOE CRY UNITS
<br />(S,.i* Yee or No)
<br />-
<br />10 RACE - (aii., White, Black American Indian, II. ANCESTRY (e.g.,Italian.
<br />eloi (Spscdy) (Spetuyl
<br />• - I
<br />Mexican, German, Mc.)
<br />I. I r'�
<br />12. MARRiED,NEVER MARRIED.
<br />WIDOWED. DIVORCED (So.cny/
<br />hi. -.
<br />13. NAME OF SPOUSE of w oe. s rnskni mule)
<br />• •:.
<br />144. UE:SAL OCCUPATION (Giro kind of work dole during mpp may,
<br />of uw8*19 iota. even d mend) LIS J!
<br />Ai:.I -I_/ - -
<br />14b: ((IND OF BUSINESS INDUSTRY
<br />••
<br />S
<br />1 1,--)
<br />- ?-
<br />I S. •.. L.•.. - . , _ •..,, -
<br />Elementary or Secondary (0-12) i College (14 or 5-)
<br />18. FATHER -NAME FIRST MIDDLE LAST '
<br />Michael H. O'Malle
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Katherine Schulte
<br />t8. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Yea, no, or ink{ I (11 Yes, give war and dales of services)
<br />Yes ) Knraae a •- A
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R_F.D. NO.. Cti t OR TOWN. STATE. ZIP;
<br />Grand Island, Ne.
<br />• a_ •' M - I 1 W_ 3 rd
<br />20a BURIAL, Cnm5lon.Ral, 120b. DA
<br />Burial 1Febr 6 1••3
<br />20c. CEMETERY
<br />Grand
<br />OR CREMATORY - NAME -
<br />Island Cemetery,Grand
<br />20d. LOCATION CITY OR TOWN STATE
<br />Island Ne
<br />2!. = - - SIG • URE & - . SE NO.
<br />4;_.,;; - r ? .1,A:,, %401 2614
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN, STATE, ZIP)
<br />n I land Nebraska
<br />ivin:stop Sonderman 6 a. �oenz_
<br />23. IMMEDIATE
<br />PART
<br />1
<br />IN.
<br />CAU (ELATE!
<br />t--
<br />ONLY CAUSE
<br />PER FOR (a). Ib;. AND (c!) t Y14arnrY between orM% and eult
<br />DUE TO, OR CONSEQUENCE OF:...
<br />belersen onset and Mean
<br />krlervtl de
<br />r--
<br />r
<br />ibl,r
<br />DUE TO, OR AS A CONSEQUENCE OF:alMrvat between owl end need+.
<br />fcl..
<br />4 ER SIGNIFICANT CONDITIONS - Candela
<br />PART
<br />II
<br />o.Ao�
<br />WMibtmno ea death but not felafad
<br />I)
<br />0+•ar`
<br />PART: III. IF FEMALE, WAS THERE A
<br />°RECN4NCY IN THE PAST 3 MONTHS?
<br />Yee 0 No
<br />24. AUTOPSY
<br />(Specay Yee cr Not
<br />YPR
<br />125 WAS CASE fad TO MEDICAL
<br />OR
<br />(Sway Yr or NO
<br />2Se. ACCI SUICIDE. HOMICIDEUNDET.,
<br />OR PENDING INVESTIGATION (SpecNyl
<br />M. DATE OF INJURY (Ho ,Day. Yr.)
<br />2bc. R OF INJURY :280. DESCRIBE HOW INJURY OCCURRED
<br />I
<br />Mf
<br />3120. INJURY AT WORK
<br />(Specify Yes of No)
<br />28t. PLACE OF INJURY - Al name, farm, street tachy,
<br />oleo* building, etc. 'Spotty) .
<br />28g. LOCATION STREET OR RFD. NO. CITY OR TOWN STATE
<br />274. DATE OF DEATH (i.1o.. Day. Yr.)
<br />February 2, 1993
<br />2E4 DATE SIGNED (Mo. Day. Yr/
<br />2Sb VASE OF DEATH
<br />IP • : DATE SIGN • ( Day Yr) 127c. TIME OF DEATH 12 39 a.
<br />„
<br />2Ec. PRONOUNCED DEAD MG. ...Sy Yr/
<br />26d PRONOUNCED DEAD (Noun ,
<br />r �
<br />`" Tome• a a.. ... wu • - tothe
<br />U,
<br />C .4S( staled. •, . �S
<br />. and Tonal► � a
<br />,���2ew�l� J►
<br />E .
<br />•-.. L
<br />weon ends Mnxn
<br />2Se Onto. bear ofeamo .M 9s. n:my amnion dwell penned at 1
<br />The bme. oil* end Pace and due m Se ca.se(s( Mind.
<br />cn
<br />n
<br />1Sgc aand 4a
<br />DID. TOBACCO USE CONTRIB. E TOT i�s.7,71611M".. 7- : r,i •ROAN OR TISSUE DONATION BEEN CUNSi D,
<br />0 YES 0 NO • UN • N LI YES
<br />WAS CONSENT GRANTED? �!/7���rl
<br />r
<br />0. YES i, CP
<br />31. NAME AND ADDRESS OF CERTIFIER (PNYSICAN. CORONER'S PHYSICAN OR COUNTY ATTORNEY). (Tye or Pant,
<br />Timothy K, Kingston MD 270N Doctors Building Omaha NE 68131
<br />} 32a32a REGISTRAR )Ma DATE FRE EY REGS' 4•A sip Day Yr)
<br />l e.�.t�a FEB 91993
<br />
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