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STATE OF NEBRASKA -DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH 1"7x,�
<br />201904901
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />1. DeVon Robert Irvine
<br />SEX
<br />2. Male
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />3. May 103 1978
<br />RACE-(e.g., White, Black, American
<br />ORIGIN/DESCENT(e.g.. talian,Mexican,
<br />AGE -last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />Indian,elc.)(Speci(y)
<br />4. White
<br />German, etc.) (Specify) .
<br />5. American
<br />(Yrs.)
<br />ba. 51
<br />MOS. DAYS
<br />6b.
<br />HOURS MINS.
<br />6c.
<br />7.Dec. 29, 1926
<br />CITY AND STATE OF BIRTH (If not
<br />name country)
<br />8. Farwell, Nebraska
<br />in U.S.A.,
<br />CITIZEN OF WHAT COUNTRY
<br />9. CSA
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED (Specify)
<br />10. Married
<br />NAME OF SPOUSE (If wife, give maiden name)
<br />11. Alvera M. (Dreher) Irvine
<br />SOCIAL SECURITY NUMBER
<br />12. �6- 2-2 •
<br />USUAL OCCUPATION (Givr rind of work done during most
<br />of working life, even if rel.r, ')
<br />W`'
<br />13a.
<br />KIND OF BUSINESS OR INDUSTRY
<br />13bMachinery I'
<br />COUNTY OF DEATH
<br />14.. Hall
<br />CITY, TOWN OR LOCATION OF DEATH
<br />14b. ` '_I. Ir _....
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />14c es
<br />HOSPITAL OR OTHER INSTITUTION - Name (If not in either,
<br />give street and number)
<br />14d. St. Francis Hospital
<br />IF HOSP. OR INST. Indicate DOA,
<br />Outpatient/Enver. Rm., Inpatient (Specify)
<br />14e. Inpa lent
<br />RESIDENCE -STATE
<br />15. - . e
<br />•FATHER
<br />COUNTY
<br />156. 9 .
<br />CITY, TOWN OR LOCATION
<br />15c. sT'TY1 j 41 n]1"
<br />STREET AND NUMBER
<br />15d. SQ�w Koenig
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />15e. Yes
<br />- NAME FIRST MIDDLE LAST
<br />16. Norton IIV] ne
<br />MOTHER -MAIDEN NAvs FIRST MIDDLE LAST
<br />17. Sanhie Waj socki
<br />WAS DECEASED -EVER IN U.S: ARMED FORCES?
<br />;Yes. no. unknown)! (It ves o war and dates of service)
<br />1B.yes WWII 1/15 2 .to 12/23']•9rg.
<br />INFOF MANT - NAME -RELATIONSHIP-MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TC1 / {U0,r 0 b(1y, ZIP)
<br />VJ.
<br />Al vera. Irvi ne-Wi fp-1504 W.Koenig Grand Island lip/BURIAL,
<br />CREMATION, REMOVAL
<br />L no. Burial
<br />DATE
<br />20b. 5/12/782oc.
<br />CEMII_,Y OR CREMATORY --NAME
<br />:alvary - Westlawn
<br />LOCATION CITY OOR TOWN STATE
<br />2od. Grand island NE
<br />EMBALMER- SIGNATURE 8 LICENSE NO. ' - 63
<br />21 ,I�- __! ,' ' 2�
<br />FUNEI <l HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />z Living ton-SondermGs1n's,505 W.Koenig, Grad Islan
<br />08801
<br />,Ne/
<br />•
<br />To be Completed by
<br />Attending PHYSICIAN
<br />Only
<br />-' e t date o u plq e d ue to the
<br />To the best o' my knowledge, death o55�cu ..
<br />causes) stated. / _c tit, ///E/,
<br />23a. (Signature and Title)
<br />To be Completed by 11
<br />CORONER'S PHYSICIAN,
<br />or COUNTY ATTORNEY
<br />only.
<br />On the basis of examination and/ori t' • my opinion {lath c erred at
<br />the time, date and place and due to, e(s) r t /
<br />24a. (Signature and sill ) •
<br />11.
<br />l
<br />DATE SIGNEDSI�✓✓(Mo., Day, Yr.)
<br />n'Aisi�•//�
<br />UR OF DEATH
<br />23c. /� c /te__ M
<br />r�iJ
<br />DATE SIG �IE (Mo. y, Yr.)
<br />�, s/ ,/
<br />24b. %
<br />HOU ATH
<br />y
<br />24c. "/.• ,-/.1,40 M
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />23d�./�D�/I'
<br />__�
<br />PRONOUNCED DEADDE(Hourr)y �/
<br />23e '. 7/�f 7/ M
<br />PRONOUNEEDjDE Day
<br />24d. Da�J/Q./%
<br />
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