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WHEN TMS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAMSERWICES
<br />SYSTEM !! CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC006 ON r4LEwTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI�AI
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OFISSUANCE Riverdale Hamlet Condo
<br />�I
<br />JUN 2 2V00 Prop. Regime C -2, Grand
<br />Island, Hall County, ASSISr,41#STATEIREGISTRA�_
<br />LINCOLN, NEBRASKA �►dE.BR• Y&DEPARTMENT OF HEALTH AND AHUMAN S�i3G� � AN_D SUMRT
<br />STATE O e-� r► I � ry
<br />CERTIFICATE V ATE OF DEATH °— - 2 0 0 0 S 3
<br />t DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3 DATE OF DEATH IM0,1M Day Year)
<br />Raymond Harold Donley
<br />Male
<br />April 4, 2000
<br />D
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Dar Year)
<br />Taloga, Oklahoma
<br />Vrsl 87
<br />February 17, 1913
<br />Sb MOS DAYS
<br />ni
<br />7 SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />• 506 -07 -1843
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />(Ages 10 -54) Yes No Y
<br />.❑ ER Outpatient Residence
<br />8b. FACILITY - Name (If not mstitufion, give street and number)
<br />2707 August
<br />❑ DOA ❑ Other iSpecd,
<br />8c. CITY TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />j8d
<br />Yea [R] N, ❑
<br />Hall
<br />ga. RESIDENCE - STATE
<br />c�
<br />-4
<br />-gtl. STREET AND NUMBER ;lnoluding Z:r Code,I 19e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />M
<br />D
<br />Gr
<br />s
<br />�a
<br />13 NAME OF SPOUSE (II wife. give maiden name)
<br />etc .I(Speotyl White
<br />fSpecdyl American '.'.
<br />Cr Cr
<br />�.
<br />❑ ❑ o
<br />MAR I
<br />_
<br />14a USUAL OCCUPATION /Give kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (SpecAy only hlghesl grade completed)
<br />Elementai or Secondary 10 121 College 11 A of i -I
<br />of worieng life. ev dretned)
<br />Dentist
<br />Orthodontics
<br />2 5+
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harrison Donley
<br />Elsie Fields
<br />18 WAS DECEASED EVER IN US ARMED FORCES'
<br />19a INFORMANT - NAME
<br />(Yes. ^n. or unk.l 111 yes give war and dates of services)
<br />Yes World War II 1941 -1953
<br />I
<br />Joan Donley__.
<br />19b INFORMANT MAILING ADDRESS ISTREET OR R D NO.. CITY OR TOWN. STATE. ZIPI
<br />2707 August, Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />_
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21C.
<br />CEMETERY OR CREMATORY NAME
<br />NOT EMBALMED
<br />El B.".1 ❑ Removal
<br />A r i 1 5, 2000 iOentral
<br />Nebraska Crerraticn Servic
<br />22. FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />CD
<br />® Cremation ❑ Donaflpn
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP(
<br />1123 West Second, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE TER ONLY ONE CAUSE PER LINE FOR 1a1. (b). AND (c)l Interval be n onset and deam
<br />PART
<br />I r v
<br />la tx� ✓l �--' I �.i
<br />CD
<br />the time, date and place and due to the causelsl s
<br />o
<br />(Signature and Title ) I
<br />ISI nature and Title
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<br />WHEN TMS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAMSERWICES
<br />SYSTEM !! CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC006 ON r4LEwTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI�AI
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OFISSUANCE Riverdale Hamlet Condo
<br />�I
<br />JUN 2 2V00 Prop. Regime C -2, Grand
<br />Island, Hall County, ASSISr,41#STATEIREGISTRA�_
<br />LINCOLN, NEBRASKA �►dE.BR• Y&DEPARTMENT OF HEALTH AND AHUMAN S�i3G� � AN_D SUMRT
<br />STATE O e-� r► I � ry
<br />CERTIFICATE V ATE OF DEATH °— - 2 0 0 0 S 3
<br />t DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3 DATE OF DEATH IM0,1M Day Year)
<br />Raymond Harold Donley
<br />Male
<br />April 4, 2000
<br />d. CRY AND STATE OF BIRTH t1f not n U S.A.. name country/
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Dar Year)
<br />Taloga, Oklahoma
<br />Vrsl 87
<br />February 17, 1913
<br />Sb MOS DAYS
<br />Sc NOURS MANS
<br />7 SOCIAL SECURTIV NUMBER
<br />8a. PLACE OF DEATH
<br />• 506 -07 -1843
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />(Ages 10 -54) Yes No Y
<br />.❑ ER Outpatient Residence
<br />8b. FACILITY - Name (If not mstitufion, give street and number)
<br />2707 August
<br />❑ DOA ❑ Other iSpecd,
<br />8c. CITY TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />j8d
<br />Yea [R] N, ❑
<br />Hall
<br />ga. RESIDENCE - STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION -- -
<br />-gtl. STREET AND NUMBER ;lnoluding Z:r Code,I 19e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2707 August 68801 Yes ® No ❑
<br />10. RACE (e.g., White. Black. American Indian
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE (II wife. give maiden name)
<br />etc .I(Speotyl White
<br />fSpecdyl American '.'.
<br />NEVER DIVORCED
<br />Joan Bricknell
<br />Homicide Investigation Y
<br />❑ ❑ o
<br />MAR I
<br />_
<br />14a USUAL OCCUPATION /Give kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (SpecAy only hlghesl grade completed)
<br />Elementai or Secondary 10 121 College 11 A of i -I
<br />of worieng life. ev dretned)
<br />Dentist
<br />Orthodontics
<br />2 5+
<br />16 FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harrison Donley
<br />Elsie Fields
<br />18 WAS DECEASED EVER IN US ARMED FORCES'
<br />19a INFORMANT - NAME
<br />(Yes. ^n. or unk.l 111 yes give war and dates of services)
<br />Yes World War II 1941 -1953
<br />I
<br />Joan Donley__.
<br />19b INFORMANT MAILING ADDRESS ISTREET OR R D NO.. CITY OR TOWN. STATE. ZIPI
<br />2707 August, Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />_
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21C.
<br />CEMETERY OR CREMATORY NAME
<br />NOT EMBALMED
<br />El B.".1 ❑ Removal
<br />A r i 1 5, 2000 iOentral
<br />Nebraska Crerraticn Servic
<br />22. FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler. - Geddes Rx>er� Hire, Inc.
<br />® Cremation ❑ Donaflpn
<br />Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP(
<br />1123 West Second, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE TER ONLY ONE CAUSE PER LINE FOR 1a1. (b). AND (c)l Interval be n onset and deam
<br />PART
<br />I r v
<br />la tx� ✓l �--' I �.i
<br />^VUt yU, UP AS A (;UNSEUUtN(:E OF ''1y�val wrveen vnam a��� �cnn
<br />DUE TO. OR AS A CONSEQUENCE OF I
<br />I rval between onset 11 deam
<br />i
<br />(c)
<br />I
<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related P
<br />PART 1
<br />111 IF FEMALE. WAS THERE A 2
<br />24 AUTOPSY 2
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PART P
<br />PREGNANCY I
<br />IN THE PAST 3 MONTHS? E
<br />EXAMINER OR CORONER'
<br />II
<br />(Ages 10 -54) Yes No Y
<br />Yes No Y
<br />Yes No
<br />26a 2
<br />26b DATE OF INJUP" /MO.. Day. Yc) 2
<br />26c. HOUR OF INJURY 2
<br />2Ed. DESCRIBE HOW INJURY OCCURRED
<br />Accident [] Undetermined M
<br />M
<br />❑ Suicide F-1 pending 6
<br />6e INJURY AT WORK 2
<br />261 PLq CE BF, INJURY - At horn farm sheet factory 1
<br />1269 LOCATION STREET OR R F D NO C
<br />CITY OR TOWN STATE
<br />Homicide Investigation Y
<br />❑ ❑ o
<br />office building, etc. /Spec/fy) 9
<br />No
<br />27a. DATE OF DEATH IMo Day Yr) 2
<br />28a DATE SIGNED (Mo. Day Yr ) 2
<br />28b TIME OF DEATH
<br />April 4 2000 -
<br />- M
<br />M_
<br />i G r 2
<br />27b DATE SIGNED (Mo.. Day. Yr) 2
<br />27c TIME OF DEATH i
<br />28C PRONOUNCED DEAD (Mo. Day. Y(1 2
<br />28d. PRONOUNCED DEAD /Noun
<br />23 A
<br />Aril 5 0 7
<br />7:38 pm M
<br />M _
<br />_ M_.__
<br />27o To to best of my k wledge. M urred al M time, to and dale and due to the °
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />__ 2
<br />° o °� 2
<br />causelsl stated. t
<br />the time, date and place and due to the causelsl s
<br />stated.
<br />(Signature and Title ) I
<br />ISI nature and Title
<br />1 ; 47 IF
<br />
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