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STATE OF NEBRASKA -DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />201900541
<br />"" DECEDENT -NAME FIRST MIDDLE LAST
<br />1.Lynn Clair Barber
<br />SEX
<br />2 Male
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />3 November 16, 1980
<br />RACE-(e.g., White, Black, American
<br />Indian, etc.) (Specify)
<br />4. Uliite
<br />ORIGIN/DESCENT(e.g., Italian, Mexican,
<br />German, etc.) Specify)
<br />S. American
<br />AGE -Lott Binhday
<br />(Y s.)
<br />6a 56
<br />_ UNDER 1 YEAR I UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />7,March 27, 1924
<br />MOS. DAYS
<br />6b.
<br />HOURS : MINS.
<br />9.
<br />CITY AND STATE OF BIRTH (If not in U.S.A.,
<br />name country)
<br />8. North Loup, Nebraska
<br />CITIZEN OF WHAT COUNTRY
<br />9. U.S.A.
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED (Specify)
<br />10. Married
<br />NAME OF SPOUSE (If wife, give maiden name)
<br />11. Betty Thomnson
<br />SOCIAL SECURITY NUMBER
<br />12. 505-22--8688
<br />USUAL OCCUPATION (Give kind of work done du ing most
<br />of working life, even if retired)i
<br />13a. Shop Foreman
<br />KIND OF BUSINESS (TR INDUSTRY COUNTY OF DEATH
<br />Nebr ska Dept.
<br />136. ot Roads ua, Hall
<br />CITY, TOWN OR LOCATION OF DEATH
<br />14b. Grand Island
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />14c. Yes
<br />HOSPITAL OR OTHER INSTITUTION - Name (I( not in either,
<br />give street and number)
<br />14d. St. Francis Medical Center
<br />IF HOSP. OR INST. Indicate DOA.
<br />Outpotient/Einer. Rm., Inpatient (Specify)
<br />ue. Inpatient
<br />RESIDENCE -STATE
<br />"Nebraska
<br />COUNTY
<br />S Hall
<br />CITY, TOWN OR LOCATION
<br />is. GrandIsland321Carey
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />15.e8
<br />iS
<br />FATHER` NAME FIRST
<br />FIRSTb. MIDDLE LAST
<br />.16. Dell -- Barber
<br />MOTHER -MAIDEN NAME FIRST MIDDLE
<br />17. hazel --- Ingerson
<br />WAS DECEASED
<br />(Yes, no, or unL)
<br />118' 18. No
<br />EVER IN U.S. ARMED FORCES?
<br />(If yet, give war and dotes of service)
<br />I____
<br />INFORMANT -NAME -RELATIONSHIP -MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE:O BR801
<br />JO
<br />19Mrs. Betty Barber -Wife -321 N. Carey -Grand Island, NE.
<br />BURIAL, Cremation, Removal
<br />20a. Burial
<br />DATEEMETERY
<br />Nov. 18, 1980
<br />20b.
<br />OR CREMATORY -NAME
<br />20c. Grand Island Cemetery
<br />LOCATION CITY OR TOWN STATE
<br />20d. Grand Island, Nebraska
<br />E ALMER-SIGNATURE d LICENSE NO. L 30
<br />''')A' lir
<br />FUNERAL HO,nZ-NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />22 Anfel-Butler --Geddes 1123 W. 2nd, Grand Island, NE. 68801
<br />> S
<br /><
<br />1u
<br />best of my Knowledge, dee • ved at the J • dote and Inc ,.d due to the
<br />cause(.) noted.
<br />-_ � '""s..a
<br />23a. (Signature and 101.1 ", .."1".. j
<br />Z>
<br />Ji Z
<br />a,0
<br />On the basis of oxo ni. stew and/o investigotion, in my opinion death occurred at
<br />the time, date and aloand due to the ...wets)...wets)stated.
<br />e.
<br />240. (Signature and 7111.1011.
<br />ei
<br />o2t
<br />116
<br />LJM.
<br />DATE SIGNED (Mo., Day, Yr.)
<br />/ I - /7- jj O
<br />HOUR OF DEATH
<br />_ 4
<br />23c. I., / 5 M
<br />X I-
<br />me4i.
<br />"ub`. Z o
<br />DATE SIGNED (Mo. Day, Yr.) HOUR OF DEATH
<br />24b. 124c. M
<br />E c
<br />°
<br />~....e^
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />23d. s
<br />. / l%l: �n�K_ l ✓ `'
<br />2 ZOO
<br />..f:`,°,.
<br />°
<br />PRONOUNCED DEAD I PRONOUNCED DEAD(Hour)
<br />(Mo., Day, Yr.)
<br />I24d. I24e. M
<br />lAn 25David Colan
<br />REGISTRAR
<br />_26o. (Signoture) 10.�
<br />27. IMMEDIATE CAUSE
<br />PART
<br />(a)
<br />V Arv, WKUr' CR J 1'RTJIt..I P,N VK L.VUN11 Al IVKN[T) (l ype or rnn
<br />M.D.
<br />729 N. Custer, Grand Island, NE. 68801
<br />(ENTER ONLY ONE CAUSE PER LINE FOR (o), (b), AND (c))
<br />csd2"L ,71 rd /Az ,4-4rc i7o
<br />DUE 10, OR AS A CONSEQUENCE OF:
<br />DATE, RECEIVED 8Y REGISTRAR (Mo., Day, Yr.)
<br />Interval between onset and deal.
<br />OA)L u� �
<br />Interval between onset and dee-
<br />th
<br />7.._ .1 _ _ ~. _ r
<br />07
<br />o y -4r
<br />Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(n)
<br />PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not related 1 PART III. IF FEMALE, WAS THERE A AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS? (Specify Yes o, No)
<br />11
<br />/�/4_cezrf4-' D . l 7 /�!17S I_
<br />ACCIDENT, SUICIDE, HOM'CID.), JHDET., DA.E OF INJI:R, (Mo., Uoy. Yr.) HOUR OF INJURY 'JE)' RIBE HOW NWURY OCCURRED
<br />OR PENDING INVESTIGATION. (Specify)
<br />Soo. /6-4 ., e SS
<br />_ 130b. 30c.
<br />INJURY AT WO°r PLACE OF INJURY- At home, farm, street, factory,
<br />(Specify Yet or No) office building, etc. (Specify)
<br />30e.
<br />'es E1 No❑
<br />M 30d.
<br />LOCATION
<br />30g.
<br />d
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />'Sootily Yes or No)
<br />29.
<br />STREET OR R.F.D. No.
<br />CITY OR TOWN STATE
<br />41, CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />E• BFr RART-if-RIM OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />` `COP'• I1 ., AN -ORIGINAL RECORD ON FILE WITH THE STATE
<br />TWENT;0 'HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />EG DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITiLi. STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued November 24, 1980
<br />
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