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Rev. 1/94 d � C O U � C rs]o U O tU c x � H � R L I- a Z E W p c W R U W r LL `. Or Lu u Z U Cl) M STATE OF NEBRASKA - DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS 200108050 CERTIFICATE OF DEATH FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part 11 ...................... TMV........................... NSC...................................................................................:....................................................................................................... ............................... ......................... Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... 0 Printed with soy Ink on recycled Paper I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. GENERA( NOTARY State of Nebraska RAYMOND A. OSEKA My Comm. E0. Nov. 2T, 2004 4LA -BUTLER- DDES FUNERAL HOME 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day. Year/ Thomas Earl McKee Male April 21, 1996 4. CITY AND STATE OF BIRTH IN nofit U.S.A. name country) Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Month. Day. Year) MOS. I DAYS x. HOURS MINI. Winterset, Iowa (Yn.l 79 5b. June 12, 1916 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 507-18-2095 -18 -2095 HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home ❑ ER Outpatient ® Residence 8b. FACILITY - Name (N not insitueon, give street and number) 621 W. 8th Street ❑ DOA ❑ Other (Specify' 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ® No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 621 W. 8th Street, 68801 Yes ® No ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. dalian. Mexican. German, sac) El MARRIED F-1 WIDOWED L1 13. NAME OF SPOUSE (It wile. give maiden name) Xlfi'�rican 7 NEVER DIVORCED MARRIED _F] Agnes Marie Schmidt 14a. USUAL OCCUPATION (Give kind of wait dare during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Spectly only highest grade completed) Elemeryay or Secondary (0.12) College It -4 or 5-I 1L ' y/"workmg/iM, even lfrekred ivtaintenance V�orker Department Store 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME ' Harry McKee Linnie Strewn 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Y.IWO or unk.) pt yes. give war and dates of services) Agnes McKee 11��11 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE ZIP) 621 W. 8th Street, Grand Island, Nebraska 68801 20. EMBaLMGNATPRE 8 NSE 1 0. 21 a. METHOD OF DISPOSITION 21b. DATE 21 C. CEMETERY OR CREMATORY - NAME #1212 Cn ❑ 04/23/1996 Westlawn Memorial Park Cemetery .trial Removal 22a. FUNERAL HOME - NAMW 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes Funeral Home ❑ cremation ❑ Donanon Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 23. IMMEDIATE C SE (ENTER ONLY ONE CAUSE PER LINE FOR lal. fb). AND Icp I Interval between onset and oeam PART ,nvll ^/O�W1• I lal I DUE TO, OR AS CONE UENCE OF: Interval between onset and oeam I I Ibl I DUE TO. OR AS A CONSEQUENCE OF, I Interval between onset and Beam I I Icl I 24. AUTOPSY 25. WAS CASE CORONER? MEDICAL INER REFERRED OTHER SIGNIFICANT CONDITIONS . Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A , PART PREGNANCY IN THE PAST 3 MONTHS. II (Ages 10 -541 Yes El No Yes No Yes No 26a. 26b. DATE OF INJURY (Mo.. Day. Yr./ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED 0 Accident r Undetermined f,, El Suicide ❑ Pending 26s. INJURY AT WORK EuildiINJURY /ll hT ,farm. sweet. IaClory S 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation yes ❑ -or Wlic ot6ee M' 27a. DA7T�E OF DEATH (MO.. Day. Yr.) 26a. DATE SIGNED (Md.. Day. Yr.) 28b. TIME OF DEATH • a sY� M 27b. DATE SIGNED (W. Day. Y I 27d TIME OF DEATH 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour) rr333r,,, � C y J Anril 23,19% 2:25 AM M B M 27d. To the beat of my k ledge. ccc at the dm , dat and place and due to the 289. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(sl stated. ' B v ;;;jjj b cause(sl stated. Si nature and Tide (Signature and Ti11a 29. DID TOBACCO USE CO NT (BUT EATH7 a HAS ORGAN OR TISSUE DONATION EEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES ❑ UNKNOWN ❑ YES ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ITYPe -# Dr. John A. Wagoner Jr., 800 Alpha, Grand Island, Nebraska 68803 32a. REGISTRAR 32D. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part 11 ...................... TMV........................... NSC...................................................................................:....................................................................................................... ............................... ......................... Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... 0 Printed with soy Ink on recycled Paper I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. GENERA( NOTARY State of Nebraska RAYMOND A. OSEKA My Comm. E0. Nov. 2T, 2004 4LA -BUTLER- DDES FUNERAL HOME