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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DERAWf*ENT O HEALTH,
<br />IT CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD ON FILE_.WITH THE STATE
<br />DEPARTMENT OFHEALTH, BUREAU OF V ?AL STATISTICS, WHICH IS THFIEGAL_ D_EPOSff_OR_YFOR
<br />V ?AL RECORDS. = j�
<br />DATE OF ISSUANCE
<br />200107964 _,-
<br />DEC 2 81994 STANLEY;S. COOPER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OE_VfiAL STATISTICS
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />GFRTIFICATE OF DEATH
<br />94.,.12025
<br />9
<br />DECEDENT - NAME FIRST !AfOC:E LAST
<br />2 SEX
<br />3. DATE OF DEATH ~M Day YOVI
<br />Clarence I. Cates
<br />I-
<br />October 5, 1994
<br />IITY AND STATE OF BIRTH land n U S.A.. rwme c"",
<br />5a. AGE - Last Birdday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16 . DATE OF BIRTH (A46nIy. Day Year)
<br />Sb. MOS DAYS
<br />M i
<br />n
<br />n
<br />January 22, 1909
<br />OCTAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 09 4225
<br />- —
<br />rrn
<br />FACILITY - Name /and rnsMUeon. gne skeet and n,nrrber/
<br />St. Francis Medical Center
<br />-n I
<br />S
<br />D
<br />8e COUNTY OF DEATH
<br />Grand Island
<br />10.
<br />Hall County
<br />9b COUNTY
<br />=
<br />96. STREET AND NUMBER /klt4A*V Zip Coda / 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />12512 W Oklahoma 68803 1 Yee ® No ❑
<br />M
<br />11 ANCESTRY leg aaMan. Mexican, German, etc)
<br />CD
<br />Q.
<br />13 NAME OF SPOUSE /k wife give maiden name/
<br />X
<br />(StecdYl
<br />American °L
<br />NEVER DIVORCED
<br />Leoda Switzer
<br />W
<br />On
<br />14b. KIND OF BUSINESS INDUSTRY
<br />-q
<br />O
<br />O
<br />Cates Tire C n
<br />Ewr 2"t 0-r SacarWany 0-121 College (1 -4 d 5.1
<br />12th Grace
<br />FATTIER - NAME FWST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles NMI Cates Dec.
<br />Edna NMI Mattson (Dec.)
<br />ID �(
<br />19a INFORMANT - NAME
<br />3> M
<br />Yes WWII 8 -26 -42 to 11 -26 -42
<br />ON
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DERAWf*ENT O HEALTH,
<br />IT CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD ON FILE_.WITH THE STATE
<br />DEPARTMENT OFHEALTH, BUREAU OF V ?AL STATISTICS, WHICH IS THFIEGAL_ D_EPOSff_OR_YFOR
<br />V ?AL RECORDS. = j�
<br />DATE OF ISSUANCE
<br />200107964 _,-
<br />DEC 2 81994 STANLEY;S. COOPER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OE_VfiAL STATISTICS
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />GFRTIFICATE OF DEATH
<br />94.,.12025
<br />9
<br />DECEDENT - NAME FIRST !AfOC:E LAST
<br />2 SEX
<br />3. DATE OF DEATH ~M Day YOVI
<br />Clarence I. Cates
<br />I-
<br />October 5, 1994
<br />IITY AND STATE OF BIRTH land n U S.A.. rwme c"",
<br />5a. AGE - Last Birdday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16 . DATE OF BIRTH (A46nIy. Day Year)
<br />Sb. MOS DAYS
<br />Sc. HOURS' MINS
<br />Wood River, Nebraska
<br />IYrs.l
<br />85
<br />January 22, 1909
<br />OCTAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 09 4225
<br />- —
<br />HOSPITAL t OTHER ❑ Nwslrlg Horne
<br />- -- ❑ ER Oulpenem ❑ Residence
<br />FACILITY - Name /and rnsMUeon. gne skeet and n,nrrber/
<br />St. Francis Medical Center
<br />❑ DOA ❑ per (Specrti —
<br />CITY TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY OMITS
<br />8e COUNTY OF DEATH
<br />Grand Island
<br />Yea No 1:1
<br />Hall County
<br />RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />96. STREET AND NUMBER /klt4A*V Zip Coda / 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />12512 W Oklahoma 68803 1 Yee ® No ❑
<br />RACE - (e g., Whoe. Black. Arnencan Indian
<br />11 ANCESTRY leg aaMan. Mexican, German, etc)
<br />12 I-0- MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE /k wife give maiden name/
<br />etc I ISoeafp
<br />White
<br />(StecdYl
<br />American °L
<br />NEVER DIVORCED
<br />Leoda Switzer
<br />USUAL OCCUPATION /Gee kkd d work done dwng m a
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (specify only tlglltal Wade corrptetedl
<br />d workxly iffR ewl 7rekw)
<br />Owner /operator �� 3
<br />Cates Tire C n
<br />Ewr 2"t 0-r SacarWany 0-121 College (1 -4 d 5.1
<br />12th Grace
<br />FATTIER - NAME FWST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles NMI Cates Dec.
<br />Edna NMI Mattson (Dec.)
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />Yes. no. or wacl (it yea. 9" war and daMs of aenvices)
<br />Yes WWII 8 -26 -42 to 11 -26 -42
<br />Leoda Cates
<br />INFORMANT MANJNU AUUHE55 IS I Mt I UH H.r.U. W., to I T UH I UYYN. b I A r L. DM
<br />2 12 W. Oklahoma, Grand Island, Nebraska 68803
<br />MER - SIGNATURE 6 LICENSE NO 21a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME
<br />EX &-w ❑ Remo.al Oct. 10, 1994 1 West Lawn Memorial Park
<br />UN HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />LJ L] Dlxwbm I Grand I
<br />3213 W. North Front St., Grand Island, Nebraska 68803
<br />Nebraska
<br />IMMEDIATE CAUSE [ENTER ONLY ONE CAUSE PER LINE FOR lal. (b), AND (e)l I Interval between onset and death
<br />PART 1 1
<br />Ial V ['J` DIY% 6N' -0 -A c 11-e- �(
<br />DUE TO, OR AS A CONSEW OF Irwerval between onset and death
<br />I
<br />ICI 1
<br />DUE TO. OR AS A CCNVSEOUENCE OF 1 Interval between onset aria death
<br />OTHER SIGNIFICANT CONDITIONS - CoMioals miff bubng Mew death but not related PART
<br />PART PREGNANCY
<br />II
<br />IN IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS
<br />AUTOPSY
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />(Ages 10-541 Yes r0-
<br />, No
<br />Yes No
<br />28b. DATE OF INJURY 11646.. Day Yr) 26c. HOUR OF INJURY
<br />26d, DESCRIBE HOW INJURY OCCURRED
<br />Accdenl UndeMrmined
<br />I M
<br />Sunda Pending
<br />Horm de Inm gMen
<br />26e. INJURY AT WORK 261 PLACEE OF, INJURY - At tgrne, farm. street. fatbry
<br />e btxltlmg, etc. /Speedy/
<br />Yes ❑ NO ❑
<br />26g. LOCATION STREET OR R F D NO. CITY OR TOWN STATE
<br />Va. DATE OF DEATH (Ab. Day. yr.)
<br />28a. DATE SIGNED (1646. Day. Yr.)
<br />28b. TIME OF DEATH
<br />October 5, 1994
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<br />Y g >
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<br />M
<br />lj� . DATE SIGNED (Ab. Day Yrl
<br />t TIME OF DEATH
<br />2 &. PRONOUNCED DEAD /1646. Day. Yr
<br />28tl. PRONOUNCED DEAD (How
<br />U
<br />October 17,1994
<br />9:30 AM M
<br />gig
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<br />27tl. To ee DeY rewleo{fe. de ee 0-h ee erne, oath and d e and tlUe b the
<br />camels)
<br />28e. On tie basis of examwiabon and,d
<br />ee bme. date and pace and due to � i op won Dean occurred 0-1
<br />° u0
<br />a
<br />Poo,
<br />( and Tree ► �'X
<br />and Tilt
<br />DID TOBACCO USE CONTRIBUTE TO TH TH7
<br />❑ YES ❑ NO UNKNOWN
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED,
<br />❑ YES le NO
<br />WAS CONSENT GRANTED'
<br />❑ YES NO
<br />t_I LAND ADMSS OF CEK"I -IEH IPHY51UAN, CORUNEK 5 PHYti N UH COUNTY ATTUMFYI (l yw d F'nw/
<br />�Ifln n f MI l mil i H &1U firinO TOW Me fiflhAl
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