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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COP /
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT ,Of .HEAM*,_ , d
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIT01Y. -FOR �l
<br />VITAL RECORDS.
<br />200109272
<br />DATE OF ISSUANCE
<br />V 198(. STANLEY S. COOPER, D.IRECTOR ,'. V.
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATIP:TZ,a$)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH � -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day, Year)
<br />Alva Ray Roe
<br />Male
<br />October 26, 1989
<br />4. CITY AND STATE OF BIRTH (if nor in U.S.A., name country)
<br />Sa. AGE - Last Birthday
<br />DAY-
<br />6. DATE OF BIRTH /Month, Day. Year/
<br />5b. MOS. I DAYS
<br />7M
<br />21111111
<br />(Yrs.)
<br />57 1
<br />Aril 11, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />88. PLACE OF DEATH V
<br />HOSPITAL: `E] Inpatient ❑ ER�Outpahent ❑ DOA
<br />290 28 8304
<br />OTHER: ❑ Nursing Home ❑ Residence ❑ Other (Specify)
<br />Bb. FACILITY -Name (d nor imshMron, give sheet and number)
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />8s. COUNTY OF DEATH
<br />VA Medical Center
<br />Grand Island
<br />(Specify Yes or N01
<br />Yes
<br />Hall
<br />c' `
<br />l't =
<br />o
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />S
<br />D
<br />Z i
<br />\
<br />I j
<br />F--+
<br />c>
<br />O
<br />°
<br />(Specify! WIDOWED, DIVORCED /Specify)
<br />Irish 0 q Married
<br />I
<br />Y
<br />14a. USUAL OCCUPATION (Give kind of worli done during twat
<br />' 4b. KIND OF BUSINESS INDUSTRY
<br />Elementary or Secondary (0.121 College 11 -4 or 5.1
<br />12th
<br />-�-�
<br />VA Medical Center
<br />CU
<br />' 7. MOTHER - MAIDEN NAME FIRST MIDDLE UST
<br />M
<br />)
<br />cn
<br />Z
<br />18. WAS DECEASED
<br />c
<br />1
<br />c 2>
<br />:M
<br />N
<br />Cc)
<br />Yes
<br />VE /1 -5- 52/9 -30 -72
<br />Patricia A. Roe 1904 W. 1st. Grand Island NE
<br />20a. BURIAL, Cremation,Removal,
<br />m 4
<br />r T
<br />LOCATION CITY OR TOWN STATE
<br />°
<br />Burial
<br />Oct. 31, 1989
<br />Westlawn Memorial Park
<br />Grand Island, Nebraska
<br />21.E MER - SIGN \T LICENSE
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) 68801
<br />o2Sr%
<br />Livingston - Sondermann 505 West Koenig, Grand Island, Ne
<br />PAW IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (D). AND Icll I Interval between onset and death
<br />',,, Cardio- pulmonary failure Days
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Congestive heart failure Days
<br />O
<br />Vii
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death bul not related
<br />PART 111 IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />6
<br />124.
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Specify Yes or No)
<br />EXAMINER OR CORONER?
<br />Massive cerebral thrombosis with coma
<br />Yes ❑ No ❑
<br />No
<br />(Specify Yes owd
<br />1V O
<br />261L ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />DATE OF INJURY (Mo.,Day, Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (SpeatyJ
<br />126b.
<br />260. INJURY AT WORK
<br />261. PUCE OF INJURY - At Lame, farm, street, factory.
<br />26q. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(sassy Yes or No/
<br />IVA
<br />office building, etc. ( Speciy)
<br />` o
<br />28a. DATE SIGNED fMo., Day, Yr.)
<br />28b. TIME OF DEATH
<br />jco
<br />+
<br />NS
<br />a
<br />�
<br />N
<br />IM
<br />27D. DATE SIGNED (MO., Defy, Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day Yr)
<br />280. PRONOUNCED DEAD (Hour)
<br />October 3i 1989
<br />7 :04 a
<br />to
<br />a
<br />CD
<br />3
<br />F
<br />3
<br />a
<br />27d. To tle Ws cumd due
<br />eauselsl
<br />!
<br />S Ti
<br />Si nature and Title
<br />211a. DID TOGA TRIB TOT 796TH?
<br />3D* . HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 300.
<br />WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES R NO
<br />ca
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Prinq
<br />N
<br />32a. REGISTRAR
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COP /
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT ,Of .HEAM*,_ , d
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIT01Y. -FOR �l
<br />VITAL RECORDS.
<br />200109272
<br />DATE OF ISSUANCE
<br />V 198(. STANLEY S. COOPER, D.IRECTOR ,'. V.
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATIP:TZ,a$)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH � -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day, Year)
<br />Alva Ray Roe
<br />Male
<br />October 26, 1989
<br />4. CITY AND STATE OF BIRTH (if nor in U.S.A., name country)
<br />Sa. AGE - Last Birthday
<br />DAY-
<br />6. DATE OF BIRTH /Month, Day. Year/
<br />5b. MOS. I DAYS
<br />5c. HOURS MINS.
<br />1
<br />Camp Dix, Kentucky �g
<br />(Yrs.)
<br />57 1
<br />Aril 11, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />88. PLACE OF DEATH V
<br />HOSPITAL: `E] Inpatient ❑ ER�Outpahent ❑ DOA
<br />290 28 8304
<br />OTHER: ❑ Nursing Home ❑ Residence ❑ Other (Specify)
<br />Bb. FACILITY -Name (d nor imshMron, give sheet and number)
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />8s. COUNTY OF DEATH
<br />VA Medical Center
<br />Grand Island
<br />(Specify Yes or N01
<br />Yes
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1904 West 1st. 68801
<br />fspecity Yes or Nol
<br />Yes
<br />10. RACE - leg., White, Black, American Indian,
<br />11. ANCESTRY (e.g-Italian, Mexican, German, etc.) 12. MARRIED,NEVER MARRIED,
<br />13. NAME OF SPOUSE (d wife, give maiden name)
<br />etc.) (St4 iy)
<br />White
<br />(Specify! WIDOWED, DIVORCED /Specify)
<br />Irish 0 q Married
<br />I
<br />Patricia Ann Cahalane
<br />14a. USUAL OCCUPATION (Give kind of worli done during twat
<br />' 4b. KIND OF BUSINESS INDUSTRY
<br />Elementary or Secondary (0.121 College 11 -4 or 5.1
<br />12th
<br />of world life, even if retired)
<br />Intor
<br />VA Medical Center
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />' 7. MOTHER - MAIDEN NAME FIRST MIDDLE UST
<br />(dec.) James Jackson Roe
<br />( Olive Marie Barrett
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />19. INFORMANT - NAME - MAILING ADDRESS - (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIPI 6 O
<br />(Yes, no, a unk.)
<br />18 yes, give war and dates ot services)
<br />1
<br />Yes
<br />VE /1 -5- 52/9 -30 -72
<br />Patricia A. Roe 1904 W. 1st. Grand Island NE
<br />20a. BURIAL, Cremation,Removal,
<br />20b. DATE
<br />20e. CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />Oct. 31, 1989
<br />Westlawn Memorial Park
<br />Grand Island, Nebraska
<br />21.E MER - SIGN \T LICENSE
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) 68801
<br />o2Sr%
<br />Livingston - Sondermann 505 West Koenig, Grand Island, Ne
<br />PAW IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (D). AND Icll I Interval between onset and death
<br />',,, Cardio- pulmonary failure Days
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Congestive heart failure Days
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Acute myocardial infarct 10 Days
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death bul not related
<br />PART 111 IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />6
<br />124.
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Specify Yes or No)
<br />EXAMINER OR CORONER?
<br />Massive cerebral thrombosis with coma
<br />Yes ❑ No ❑
<br />No
<br />(Specify Yes owd
<br />1V O
<br />261L ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />DATE OF INJURY (Mo.,Day, Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (SpeatyJ
<br />126b.
<br />260. INJURY AT WORK
<br />261. PUCE OF INJURY - At Lame, farm, street, factory.
<br />26q. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(sassy Yes or No/
<br />IVA
<br />office building, etc. ( Speciy)
<br />27a. ATE OF DEATH (Mo., Day, Yr.)
<br />28a. DATE SIGNED fMo., Day, Yr.)
<br />28b. TIME OF DEATH
<br />a
<br />October 26 1989
<br />a
<br />�
<br />IM
<br />27D. DATE SIGNED (MO., Defy, Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day Yr)
<br />280. PRONOUNCED DEAD (Hour)
<br />October 3i 1989
<br />7 :04 a
<br />to
<br />a
<br />3
<br />F
<br />3
<br />a
<br />27d. To tle Ws cumd due
<br />eauselsl
<br />28e. On the basis of examination and/or investigation. In my opinion death occurred at
<br />the time, date and place are due to the causels) stated.
<br />S Ti
<br />Si nature and Title
<br />211a. DID TOGA TRIB TOT 796TH?
<br />3D* . HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 300.
<br />WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES R NO
<br />D YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Prinq
<br />Hugh J. Woods, M.D., VA Medical Center, 2201 N. Broadwell, Grand Island, NE 68803
<br />32a. REGISTRAR
<br />320. DATE FILED BY REGISTRAR (Mo. Day, Yr.J
<br />N OV 3 1989
<br />Lot 10 in Fr. Block 3, Charles HTasrer's Addition to the city of r1rand Island
<br />
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