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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELQW.a_
<br />OF AN ORIGINAL RECORD ON FILE WITH THE SQA, �A
<br />BUREAU OF VITAL STATISTICS, WHICH IS THS
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />APR 2 1 1986
<br />LINCOLN, NEBRASKA
<br />202206467
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH.
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH `, J
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />1 Johnson Eugene Story
<br />SEX
<br />? male
<br />DATE OF DEATH (Mo., Dor. Tr.)
<br />4. April 13, 1986
<br />RACE-(o.g., White. Slack, American
<br />Indian, ek.) (Specify)
<br />4. White
<br />ORIGIN/DESCENT
<br />German, MO
<br />s. En
<br />(0.0., Italian, Mimic n,
<br />/Specify/
<br />lish 0
<br />AGE -Lest tinhdoy
<br />(Yrs.)
<br />6o, 70
<br />UNDER 1 YEAR 1 UNDER 1 DAY
<br />DATE Of BIRTH (Me., D07. Yr.)
<br />7April 15. 1915
<br />MOS. i DAYSHOURS : MINS.
<br />6b. (6c.
<br />CITY AND STATE Of BIRTH (N net in U.S.A.,
<br />none country))19
<br />4. Winston, Mi _COT ri
<br />CITIZEN Of WHAT COUNTRY
<br />9. _Tj S A
<br />MARRIED,
<br />WIDOWED,
<br />10. marria
<br />NEVER MARRIED,
<br />DIVORCED(Specify)
<br />NAME OF
<br />tl.
<br />SPOUSE (Waif*, give maiden name)
<br />ary _Luella Shopinakpr
<br />SOCIAL SECURITY NUMBER USUAL OCPAT ON (Give kind of work done during most
<br />of working life, even if refired)
<br />12.498-16-3627 13o. Attogney
<br />KIN BUSINESS OR INDUSTRY
<br />13b.Self-pmpinyed
<br />COUNTY OF DEATH
<br />140. Hall
<br />CITY, TOWN OR LOCATION OF DEATH
<br />14Grand Island
<br />INSIDE CITY LIMITS
<br />(Specify Yet or No)
<br />' c. Yes
<br />HOSPITAL OR OTHER INSTITUTION - Name (IT net in (fither,
<br />give One and number)
<br />141VA Medical nter
<br />0 14011 OR INST. Indite'. DOA,
<br />Outpatient/(mer. Rm., Inpatient (Specify)
<br />14.. Inp at' pnt
<br />RESIDENCE - STATE
<br />illr 1seNebraska
<br />COUNTY
<br />I
<br />11sb. Hall
<br />CITY, TOWN OR LOCATION
<br />15e. Grand Is and
<br />STREET AND NUMBER
<br />15d. 816 West 2nd
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />lS..vp
<br />FATHER -NAME fl T MIDDLE LAST
<br />B )6. (dec.) Guy L. Story
<br />MOTHER -MAIDEN NAME FIRST MIDDLE LAST
<br />17. (dee.) Mab1P Johnson
<br />WAS DECEASED
<br />(Yet. no, es unk)
<br />► is.Yes
<br />EVER IN U.S. ARMED FORCES?
<br />I (14 yes, give ivor end dohs o1 service)
<br />WWII/8-5-42/10-26-45
<br />INFORMANT -NAME -RELATIONSHIP -MAILING ADDRESS (STREET OR R.F.D. 740.. CITY OR TOWN. STATE, ZIP)
<br />Wife
<br />19.Mrs. Mary Story, R16 .Wpc1- 2 Grand Ta1and Daz 68801
<br />BURIAL, Cremation, Removal
<br />20o. C mation
<br />DATE
<br />Apri1•16, 1986
<br />20b.
<br />CEMETERY ORCREACATORY-NA7AE
<br />20., Lincoln Memorial Cremator
<br />l ATION CITY ONTO*N STATE
<br />od. Lincoln, Nebraska
<br />EMB . IGNATU 6 LICENSE
<br />>i
<br />NO. O/lc
<br />7
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO.. cin OR TOWN. STATE. ZIPI
<br />Apfel-Butler -Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />a
<br />u•A•C
<br />O (Mo., ay, Yr.)
<br />23o. Apr 1 13. 1986
<br />Tse
<br />S'i ,.
<br />Z
<br />U Ir.;
<br />0
<br />sO, ui a
<br />v
<br />DATE SIGNED (Mo. Day, Yr.)
<br />240.
<br />HOUR Of DEATH
<br />24b. M
<br />DATE SIGNED (Mo., Doy, Yr.)
<br />23b. '• 1;.
<br />HOUR OF DEATH
<br />23c. '• 4 B • M
<br />PRONOUNCED DEAD
<br />NO.. Dor, Yr.)
<br />24c.
<br />PRONOUNCED DEAD (Hour)
<br />24d. M
<br />To rhe best of e4 Leevddg., death • r . the
<br />ceute(tl ta»d• / -
<br />23d. (Signature and Tido �X(„/
<br />•u1% •nnaeee 'Se •-eev.e.ee reuverrr•u
<br />do,.. dots
<br />�enndd lace and due ts the
<br />0\��•�•• {
<br />CM�"u 1 1,1 0
<br />r•r.anduee.e e...,e,••.i.. ...se r•r.....Te •evrse..e6...___
<br />On O m basis o1 e.on.inorien and/or investigation, in my opinion dead+ ocwrted ar
<br />Me time. dote and piece and des to Me eause(t) stored.
<br />24e. (Signotero and limy
<br />__ m_._„
<br />2s C. D. DANIELSON, M.D., V1�MPdiral_
<br />REGISTRAR
<br />26o.(Signeruri11111.
<br />27. IMMEDIATE CAUSE
<br />PART
<br />(o) Pneumonia
<br />e
<br />('pntpr,22(11 N Rrna
<br />(ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c))
<br />OATS REEVED tEGISTRA� (thio.', o,f,7 rT88n1
<br />APR 17 1986
<br />26b.
<br />Imrervol between onset and death
<br />1 Week
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />(b) Gram negative septicemia
<br />Interval between orison ed death
<br />1 Week
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(r) Rectal abscess
<br />PART OTHER SIGNIFICANT CONDITIONS-Coeditiom contributing to death but net °doted
<br />H Chronic lymphocytic leukemia
<br />Interval bes.een onset and death
<br />3 Weeks
<br />PART 111. If FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes 0 No 0
<br />AUTOPSY
<br />(Specify Yes .. No)
<br />22. No
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Specifikre . Ne)
<br />29. 11
<br />ACCIDENT. SUICIDE. HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION. (Specify)
<br />30o.
<br />DATE Of INJURY (Mo., Day, Yr.)
<br />30b.
<br />HOUR Of INJURY
<br />30c.
<br />M
<br />DESCRIBE NOW INJURY OCCURRED
<br />30d.
<br />INJURY AT WORK
<br />(Specify Yes or No)
<br />30o.
<br />,LACE Of NJURY- As home, tern., smear. factory,
<br />office building. etc. (Specify)
<br />30f.
<br />LOCATION STREET OR R.F.O. No.
<br />3081.
<br />CITY OR TOWN STATE
<br />
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