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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 C�:;'Y
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT,
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSZ
<br />VITAL RECORDS n o J I 836
<br />L i A
<br />DATE OF ISSUANCE
<br />OCT 2 41989
<br />LINCOLN, NEBRASKA
<br />Amended October 24, 1989
<br />•
<br />+ f
<br />STANLEY S. COO''•b
<br />, IRECToi. ..
<br />BUREAU OF VITAL SI T ��
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH _ /,., ( )
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />Billy Lee Myers
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Month. Day. Year)
<br />September 21, 1989
<br />4. CITY AND STATE OF BIRTH (if not in U.S.A., name country)
<br />Kensington, Kansas `
<br />Se. AGE - Last Birthday
<br />(Yre.)47
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH (Month. Day. Year)
<br />October 20, 1941
<br />5b. MOS. I DAYS
<br />5c. HOURS' MINS.
<br />I
<br />07. SOCIAL SECURITY NUMBER
<br />505-44-2974
<br />8e. PLACE OF DEATH
<br />HOSPITAL: 0 Inpatient 0 ER/Outpatient 0 DOA
<br />OTHER: 0 Nursing Home 1 Residence 0 Other (Specify)
<br />8b. FACILITY - Name (if not institution, give Street and number)
<br />3004 West 14th St.
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />8d. INSIDE CITY UMITS
<br />(SpeedyYes or No)
<br />Yes
<br />8e. COUNTY OF DEATH
<br />Hall
<br />9a RESIDENCE • STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY. TOWN OR LOCATION
<br />Grand Island
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />3004 W. 14th St.
<br />9e. INSIDE CITY UMITS
<br />ISpecify Yea or No)
<br />Yes
<br />10. RACE • (e.g., White.. Black. American Indian,
<br />etc.) (Specify)
<br />White
<br />11. ANCESTRY (e.g.,ltalian, Mexican, German, etc.)12.
<br />(Speciy) A
<br />American
<br />MARRIED,NEVER MARRIED,
<br />WIDOWED, DIVORCED (Specify)
<br />Married
<br />13. NAME OF SPOUSE hi ' ' maiden nyme)
<br />be a
<br />Patricia
<br />148. USUAL OCCUPATION (Give kind of work done during most
<br />of working life, even if retired)
<br />Thir
<br />Owner/Operatord Cit
<br />Drywall
<br />14b. KIND OF BUSINESS INDUSTRY
<br />Construction
<br />15 EDUCATION ISnacily only hioheat made comokaael
<br />Elemem$ry m Secondary (0-12) I College (1.4 or 5+1
<br />12 I
<br />11B. FATHER - NAME FIRST
<br />Glenn MIDDLE UST
<br />E. Myers
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Anna M. Watson
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Yes, no, or u n .) I 18 yes, give war and dates of services)
<br />No
<br />19. INFORMANT • NAME • MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STAT DP)
<br />8 i
<br />Patricia Myers -Wife -3004 W. 14th St.-Mindstand,
<br />20a. BURIAL, Cremation,Removal,
<br />Donation
<br />21. EMBAL
<br />20b. DATE
<br />Sept. 23, 1989
<br />NATURE d L - SE NO. 2 044,7
<br />/ / i .i -
<br />23. i DI E ' f
<br />PART
<br />Id
<br />20c. CEMETERY OR CREMATORY - NAME
<br />Grand Island Cemetery
<br />200. LOCATION CITY OR TOWN STATE
<br />'Grand Island, Nebraska
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, 2IP) 68801
<br />Apfel-Butler-Geddes 1123 W. 2nd, Grand Island, NE.
<br />DUE TO, OR AS A ONSEOUENC
<br />Ibl
<br />(ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), A(Q (c))
<br />8 -,cryo C c\osr c " ct\Z' tsV n�C.r\ouJn
<br />Df:
<br />Interval between onset and death
<br />Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not related
<br />PART
<br />IICINO
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Ven No ❑
<br />24. AUTOPSY
<br />(Specify Yes or No)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />(Specify Yes or No) No
<br />28a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION (Specify)
<br />28b. DATE OF INJURY (Mo.,Day, Yr.)
<br />28c. HOUR OF INJURY
<br />M_
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />28e. INJURY AT WORK
<br />(Specify Yes or No)
<br />•
<br />261. PLACE OF INJURY - At home, Farm, street factory,
<br />office building. etc. (Specify) •
<br />26g. LOCATION STREET OR R.F.D. NO. . CITY OR TOWN STATE
<br />a
<br />g
<br />S
<br />F
<br />27a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 1989
<br />$ H `$
<br />Fo
<br />6
<br />28a. DATE SIGNED (Mo., Day. Yr.)
<br />28b. TIME CF DEATH
<br />M
<br />28c.PRONOUNCED DEAD (Ma, Day, Yr.)
<br />29d. PRONOUNCED DEAD /Noun
<br />M
<br />27b. DATE SIGNED (Mo., Day. Yr.)
<br />September 25, 1989
<br />27c. TIME OF DEATH
<br />9:50 a. m. M
<br />288. On the basis of examination alMlOr inv831igaadn, in my opinion death occurred et
<br />, the time, date and place and due to ate causes) stated.
<br />(Signature and Title) IP
<br />my gRf dpe, occurred a ,date aa9944p1ace and due to the
<br />27d. To the beat of kn e8
<br />causes) stated. \\
<br />,Signature and TiIlel► d� ^ �'`\1'
<br />29a DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES)444O 0 UNKNOWN
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES.g NO
<br />300. WAS CONSENT GRANTED?
<br />OYES 40
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />J.J. Cannella M.D. 729 N. Custer, Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day Yr.)
<br />SEP 2 8 1989
<br />
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