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WHEN THIS COPY CARR ES THE RAISED SEAL OF THE NEBRAS MAN SERVICES
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF T� � ft£ ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, 1M& MM&W -nQN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />t:A#Lfft COOPER
<br />JUN 18 1998 = ASSISTANT S1:ATEMGISTRAR
<br />LINCOLN, NEBRASKA HEAt-THAl1RN - SER14dESSYSTEM
<br />7 Q
<br />STATE
<br />OF NEBRASKA- DEPARTMENT OF HEALTH A1&Ht$4AN SERVICES Flf"_ CE AND SUPPORT
<br />vrrAL STAnstid
<br />a rF.R TTFTC' A TR (lF rl-t!�Axa --
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3, DATE OF DEATH /Month Day. year)
<br />�
<br />n
<br />n
<br />4. CITY AND STATE OF BIRTH tHnot in USA. namecounkyl
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH nMorrdr. Day. Year)
<br />MOS. DAYS
<br />5c. HOURS' MINS.
<br />Franklin, Pennsylvania
<br />(Yrs. 5b
<br />74
<br />T
<br />I
<br />=
<br />D
<br />205-12-4185
<br />HOSPITAL. ❑ Inpatient OTHERS ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />8b. FACILITY -Name la not mshh tbn, give street and number/
<br />Saint Francis Medical Center
<br />&efil
<br />8c. CITY TOWN OR LOCATION OF DEATH
<br />80. INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island
<br />Yes No --
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />o
<br />9e INSIDE CITY Lim, TS
<br />C::)
<br />�
<br />Grand Island
<br />324 E. 14th St. 68801
<br />>
<br />`
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etcl
<br />12. © MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /a wvle give maiden name)
<br />`
<br />ISPeci 1
<br />" American
<br />I
<br />c� 2�
<br />'a
<br />N
<br />CTS
<br />\ C?
<br />m
<br />c .
<br />ruck Driver
<br />J
<br />Construction
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />ITnknown
<br />Mary NMN McCollum
<br />18. WAS CECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />i
<br />(Yo:. nc or unk.)
<br />PIZ
<br />Yes
<br />Aug. 29, 1942- Ict,5, 194
<br />June M. Thomas
<br />CID
<br />324 E. 14th St., Grand Island, Ne. 68801
<br />O
<br />C) `*t
<br />C:)
<br />CEMETERY OR CREMATORY NAME
<br />®Bur al ❑ Remo
<br />"I June 8, 1998
<br />Westlawn Memorial Park
<br />22a. FUNERAL H - NAME
<br />21C CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H. °
<br />-( "'alm Dwauon
<br />❑ ❑
<br />I Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ner 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at. fbl. AND (c)) Interval between onset and deair
<br />PART
<br />It //JJ /'
<br />DUE TO. OR AS A CONSEPUENCE OF I Interval between onset and seam
<br />or j1 . .F� S L V -1)
<br />-DUE TO. OR AS A CONSEQUENCE OF - - - - i ery ai between orcer a�a n�a�
<br />l Ici
<br />PARIT, OTHER SIGNIFICANT CONDITIONS - Conditions c3ntribuhng to the death but not related PART
<br />111 IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />�i PREGNANCY
<br />IN THE PAST 3 MONTHS? �/'
<br />/'Yes
<br />EXAMINER OR CORONER'
<br />!Ages
<br />10 -54) Yes NO
<br />No
<br />Vey NO
<br />26a
<br />26b. DATE OF INJURY /Mo.. Day. Yc)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />429- `1 ',
<br />M
<br />(�
<br />n
<br />261 PLLAqCE OF INJURY - At home- farm. svee;. factory
<br />ollice building. etc /SOecifyl
<br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br />r'
<br />Yes No ❑
<br />1
<br />y
<br />j'
<br />v-
<br />27a DATE OF DEATH (Mo.. Day ✓rl
<br />28a. DATE SIGNED lido. Day yr)
<br />1 28b TIME OF DEATH
<br />ids
<br />�,
<br />i
<br />c
<br />r Cn
<br />• M
<br />27b. DATE SIGNED (MO.. My. vrl
<br />0o
<br />28c. PRONOUNCED DEAD /MO.. Dry, Yr.)
<br />28d. PRONOUNCED DEAD /Fbun
<br />61
<br />>
<br />z`i
<br />k JUNE 8 1998
<br />a' 12.20 A M
<br />;K
<br />M
<br />g
<br />8
<br />v
<br />27d. To the best of my knowledge. death occurred at the time date and place and due to the
<br />28e. On the burs of examination and,or investigation, in my opinion death occurred at
<br />rse(s) stated. I
<br />I
<br />c� B
<br />the time, dale and place and due to Me dausela) slated.
<br />C:3
<br />co
<br />cc
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />Jy ❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />1/ ❑ YES NO �-
<br />ZA-
<br />WHEN THIS COPY CARR ES THE RAISED SEAL OF THE NEBRAS MAN SERVICES
<br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF T� � ft£ ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, 1M& MM&W -nQN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />t:A#Lfft COOPER
<br />JUN 18 1998 = ASSISTANT S1:ATEMGISTRAR
<br />LINCOLN, NEBRASKA HEAt-THAl1RN - SER14dESSYSTEM
<br />7 Q
<br />STATE
<br />OF NEBRASKA- DEPARTMENT OF HEALTH A1&Ht$4AN SERVICES Flf"_ CE AND SUPPORT
<br />vrrAL STAnstid
<br />a rF.R TTFTC' A TR (lF rl-t!�Axa --
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3, DATE OF DEATH /Month Day. year)
<br />Charles F. Thomas
<br />Male
<br />June 4, 1998
<br />4. CITY AND STATE OF BIRTH tHnot in USA. namecounkyl
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH nMorrdr. Day. Year)
<br />MOS. DAYS
<br />5c. HOURS' MINS.
<br />Franklin, Pennsylvania
<br />(Yrs. 5b
<br />74
<br />May 27, 1924'
<br />7. SOCIAL SECURITY NUMBER
<br />Be . PLACE OF DEATH
<br />205-12-4185
<br />HOSPITAL. ❑ Inpatient OTHERS ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />8b. FACILITY -Name la not mshh tbn, give street and number/
<br />Saint Francis Medical Center
<br />❑ DOA ❑ Other(Specdy,
<br />8c. CITY TOWN OR LOCATION OF DEATH
<br />80. INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island
<br />Yes No --
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncludmg & Code!
<br />9e INSIDE CITY Lim, TS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />324 E. 14th St. 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American kidian
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etcl
<br />12. © MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /a wvle give maiden name)
<br />etc.) ISoecnfy)
<br />White
<br />ISPeci 1
<br />" American
<br />I
<br />NEVER DIVORCED
<br />MARRIED
<br />I June M. Packard
<br />14a USUAL OCCUPATION /Give kind of work done during most ,_ j lab.
<br />of workr life, even it retired) (?
<br />KIND OF BUSINESS INDUSTRY ^^
<br />15. EDUCATION ISpeci" only highest grade completed)
<br />Elam rZg SeyMy(fe 21 College it -4or 5 -1
<br />�ZSj rl (ir Q
<br />ruck Driver
<br />J
<br />Construction
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />ITnknown
<br />Mary NMN McCollum
<br />18. WAS CECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yo:. nc or unk.)
<br />III yns. give war and dates of services)
<br />Yes
<br />Aug. 29, 1942- Ict,5, 194
<br />June M. Thomas
<br />19b. INFORMANT MAILING ADDRESS ;STREET OR R F D NO CITY OR TOWN STATE. ZIP)
<br />324 E. 14th St., Grand Island, Ne. 68801
<br />20 EMIL R - SIG URE LICENSE
<br />^
<br />2Ta METHOD OF DISPOSITION
<br />' 21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />®Bur al ❑ Remo
<br />"I June 8, 1998
<br />Westlawn Memorial Park
<br />22a. FUNERAL H - NAME
<br />21C CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H. °
<br />-( "'alm Dwauon
<br />❑ ❑
<br />I Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ner 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (at. fbl. AND (c)) Interval between onset and deair
<br />PART
<br />It //JJ /'
<br />DUE TO. OR AS A CONSEPUENCE OF I Interval between onset and seam
<br />or j1 . .F� S L V -1)
<br />-DUE TO. OR AS A CONSEQUENCE OF - - - - i ery ai between orcer a�a n�a�
<br />l Ici
<br />PARIT, OTHER SIGNIFICANT CONDITIONS - Conditions c3ntribuhng to the death but not related PART
<br />111 IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />�i PREGNANCY
<br />IN THE PAST 3 MONTHS? �/'
<br />/'Yes
<br />EXAMINER OR CORONER'
<br />!Ages
<br />10 -54) Yes NO
<br />No
<br />Vey NO
<br />26a
<br />26b. DATE OF INJURY /Mo.. Day. Yc)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261 PLLAqCE OF INJURY - At home- farm. svee;. factory
<br />ollice building. etc /SOecifyl
<br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br />Homicide lnvesugatwn
<br />❑❑
<br />Yes No ❑
<br />1
<br />27a DATE OF DEATH (Mo.. Day ✓rl
<br />28a. DATE SIGNED lido. Day yr)
<br />1 28b TIME OF DEATH
<br />ids
<br />X JUNE 0q/ 1998
<br />='
<br />3
<br />• M
<br />27b. DATE SIGNED (MO.. My. vrl
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /MO.. Dry, Yr.)
<br />28d. PRONOUNCED DEAD /Fbun
<br />61
<br />>
<br />z`i
<br />k JUNE 8 1998
<br />a' 12.20 A M
<br />M
<br />g
<br />8
<br />v
<br />27d. To the best of my knowledge. death occurred at the time date and place and due to the
<br />28e. On the burs of examination and,or investigation, in my opinion death occurred at
<br />rse(s) stated. I
<br />I
<br />c� B
<br />the time, dale and place and due to Me dausela) slated.
<br />IS12nature and Title
<br />ISi nature arb Tilt
<br />29. DID TOBACCO USE CONTRIBUTE T THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />Jy ❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />1/ ❑ YES NO �-
<br />ar. NAiwE AND nub -HESS Or GtH I witH IPHYMUTAN, CORONER 5 PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />��BARTON D. URBAUEPA.MD 2444 Ink E.AIDLEY. GRAND ISLAND NE 68803
<br />
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