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Rev 1/94 <br />DECEDENT <br />LL <br />0 <br />W <br />2 <br />z <br />N <br />C <br />O <br />0 <br />U <br />C <br />0 <br />U <br />O <br />a) <br />C <br />E <br />f0 <br />5K <br />m <br />a) <br />U <br />a) <br />a) <br />E <br />C <br />cV <br />U <br />U, <br />Joa <br />T <br />0) <br />rn <br />`O <br />ll. <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />201903432 <br />FOR VITAL STATISTICS USE ONLY <br />Place A B C D E Part II TMV <br />NSC Census Tract Ni <br />Work <br />UC <br />Reject <br />I. DECEDENT - NAME FIRST MIDDLE LAST <br />Philip Dean Lowry <br />2 SEX <br />Male <br />3 DATE OF DEATH /Month. Day. Year/ <br />February 9, 1994 <br />4 CITY AND STATE OF BIRTH IS nal m USA. name country/ <br />5a AGE , Last Birthday <br />UNDER I YEAR <br />UNDER I DAY <br />6. DATE OF BIRTH (Month Day Year) <br />Grand Island, Nebraska <br />(Yrs <br />�8I <br />5b MOS I DAYS <br />5c. HOURS' MINS. <br />f <br />August 19, 1925 <br />Z 7. SOCIAL SECURTIY NUMBER <br />0 506-38-6647 <br />8a. PLACE <br />OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient a. Residence <br />❑ DOA ❑ Olher(Specdyr <br />U. 8b. FACILITY - Name (If not institution, give street and number) <br />0 1508 Post Place <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island <br />Bd. NSIDE <br />Yes <br />CITY LIMITS <br />E No ❑ <br />Be COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b COUNTY <br />Hall <br />Sc. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip (ode) <br />1508 Post P1 68801 <br />9e. INSIDE CITY LIMITS <br />Yes E No <br />10. RACE - (e.g., While. Black. American Indian. <br />etc.) (Specify( <br />White <br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc( <br />(Speclly) <br />German/Irish <br />12. <br />x <br />ElNEVE <br />MARRIED ❑ WIDOWED <br />MARRIR ED DIVORCED <br />❑ <br />13. NAME OF SPOUSE (If wile. give maiden name) <br />Maxine Waskowiak <br />14a. USUAL OCCUPATION (Give kind o, work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />CA o/ working life, even if retired) <br />F- Farmer <br />Agriculture <br />Elemenlary or Secondary 10-12) College (1 .4 or 5• I <br />12 <br />WI6. FATHER - NAME FIRST MIDDLE LAST <br />CC <br />Roland Lowry <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Edith Rickert <br />d <br />18. WAS DECEASED <br />JYYes. no. or Link.) <br />N <br />EVER IN U.S. ARMED FORCES? <br />I (If yes. give war and dates of services) <br />19a. INFORMANT <br />Maxine <br />- NAME <br />Lowry <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, <br />1508 Post Place Grand Island, Nebraska 68801 <br />STATE. ZIP) <br />70 F.MRAIMFR- SIGNA TUFT R I ICFNSF: Nn <br />Not Embalmed <br />21n Mr mon OF nl;PO$IT <br />❑ Burial ❑ Removal <br />Ir1N <br />21h DA II <br />FEB 9, 1994 <br />21, TIMr IFRY TIII Ma' MA I ow NAME <br />Central NE Cremation Servi <br />22a. FUNERAL HOME - NAME <br />Apfel-Butler-Geddes Funeral Ho <br />Cremation ❑Donation <br />21d CEMETERY OR CREMATORY LOCATION <br />Gibbon, Nebraska <br />CITY OR TOWN STATE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Street Grand Island, Nebraska <br />68801 <br />W <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER <br />PART <br />I(el Cerebral vascular accident <br />LINE FOR Ial. Ibl. AND (c(( <br />Interval between onset and dealh <br />arot <br />U <br />DUE TO, OR AS A CONSEQUENCE OF <br />Type I Diabetes mellitus <br />Interval between onset and death <br />DUE TO. OR AS A CONSEQUENCE OF' <br />(c) Hypertension <br />Interval between onset and death <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />11 Carcinoma,colon <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10-54) Yes -1 No ❑ <br />24 AUTOPSY <br />Yes � No � <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Yes ❑ No <br />26a. <br />Accident . Undetermined <br />26b. DATE OF INJURY (Mo.. Day, Yr.) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OCCURRED <br />• Suicide . Pending <br />Homicide Investigation <br />26e. INJURY AT WORK 1261. PACE OF. INJURY .(p hom , farm. street factory <br />❑ ❑ I o Ice I ding, etc. /Speciy/ <br />Yes No <br />26g. LOCATION STREET OR R.F.D NO. CITY OR TOWN STATE <br />To be ComdeleC DY <br />L ACeMCg PHYSICIAN <br />ONLY <br />27a. DATE OF DEATH (Mo.. Day Yr.) <br />9 February 1994 <br />s� <br />S3< <br />2Ba. DATE SIGNED (Mo.. Day. Yr/ <br />28b. TIME OF DEATH <br />Z <br />27b. DATE SIGNED (Md. Day. Yr) 27e. TIME OF DEATH <br />9 February l9 /1/ 12:05 p <br />l 5 <br />28c. PRONOUNCED DEAD IMo.. Day. Yr) <br />28d. PRONOUNCED DEAD (Hourl <br />4 <br />T <br />II <br />27d. To the best of my knowledge., odc rr§§gl��i at 1 time, date and pl e�and due to the <br />, mature ) stated. i / / i /� i' - /� <br />(Signature and Title) ► V ,- �� <br />1 cv <br />c� a <br />28e. On the basis of examination and/or investigation, in my opinion death occurred at <br />6.the time, date and place and due Io the causels sealed. <br />(Si nature and Title) ► <br />29. DID TOBACCO USE CONTRIB TO THE EAT 7 <br />❑ YES NO ❑ UNKNOWN <br />30.a HAS ORGAN OR TISSUE DONATION BEEN NSIDERED? <br />❑ YES NO <br />30.b WAS CONSENT GRANTED? <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) <br />Dr. William Lawton 2444 West Faidley Grand Island, NE 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo. Day Yr.) <br />FOR VITAL STATISTICS USE ONLY <br />Place A B C D E Part II TMV <br />NSC Census Tract Ni <br />Work <br />UC <br />Reject <br />