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2 Q1 937 <br />WHEN THIS COPYCATS TIE RAISED SEAL OF THE NEBRASKA HEALTH '= _' • ry « <br />SYSTFEA4 T CERTIFES TIE: BELOW TO BEA TRUE COPY OF THE ORIGINAL <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISIICLIW <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS �Y <br />DATE OF ISSUANCE <br />JUN 11 1997 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTi . <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />John Gaylord Eastman, Sr. <br />2. SEX <br />Male <br />3. DATE OF DEATH (Mont/S Dat Year) <br />May 29, 1997 <br />4. CRY AND STATE OF BIRTH /Mnot N USA. name country) <br />Sioux City, Iowa <br />5a AGE • Last Birthday <br />(Yrs.) <br />61 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Year) <br />May 21, 1936 <br />Sb. MOS. 1 DAYS <br />, <br />5c. HOURS I MINS <br />7. SOCIAL SECURTIY NUMBER <br />479-40-7773 <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER: ❑ Nursing Hare <br />\ <br />153 ER Outpatient ❑ Residence <br />❑ DOA ❑Other(Speclyl <br />8b. FACILITY • Name (M not inabtutlon, give street and number) <br />St. Francis Medical Center <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />L Grand Island <br />8d. INSIDE <br />Yes <br />CITY LIMITS <br />r No ❑ <br />Be. COUNTY OF DEATH <br />Hall . <br />ribs RESIDENCE - STATE <br />Nebraska <br />90 COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />90. STREET AND NUMBER (InckaringZa Code) <br />_ 616 North Kimball, 68801 <br />Be. INSIDE <br />Yes <br />CITY <br />i7 <br />LIMITS <br />No ❑ <br />10. RACE • (e.g. White. Black. American Indian, <br />WiIT1 <br />11. ANCESTRY (e.g.. IWIBn. Mexican. German, etc) 19 <br />American 1Y <br />12. <br />, m <br />❑AR;IED <br />MARRIED <br />iiM/wd <br />❑ <br />WIDOWED <br />DIVORCED <br />13. NAME OF SPOUSE e give maiden name) <br />Beverly J. Prawl <br />14a. USUAL OCCUPATION (Give tended work done dwhgmost <br />o/ working Moeven ifretired) Al'" <br />Nursing Aid <br />14b. KIND OF BUSINESS INDUSTRY ‘ <br />' <br />Veterans Affair Medical Center <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary (0.121 ' College 11-4 or 5.1 <br />10 <br />18. FATHER - NAME FIRST MIDDLE LAST <br />Benje Eastman <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Myrtle Irene Giesbers <br />18. WAS DECEASED <br />(Yes. no. or unk.) <br />Yes <br />EVER IN U.S. ARMED FORCES?...- <br />I I8 yea give war and dates of services) <br />5-19-56 5-18-62 , <br />tSa. INFORMANT -NAME <br />Beverly Eastman <br />19b .INFORMANT MAILING ADDRESS (STREET OR R.F.D.. NO.. CITY OR TOWN. STATE. ZIP) <br />616 North Kimball, Grand Island, Nebraska 68801 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO. <br />Not Embalmed <br />21a. <br />❑ <br />C9 <br />METHOD OF DISPOSITION <br />Burial ❑ Removal <br />Cremation ❑ Donation <br />21b. DATE <br />05/29/1997 <br />21 c. CEMETERY OR CREMATORY • NAME <br />Central NE Cremation Service <br />22a FUNERAL HOME - NAME • <br />Apfel-Butler-Geddes Funeral Home <br />2W. CEMETERY OR CREMATORY LOCATION <br />Gibbon, Nebraska <br />CITY OR TOWS! STATE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIP) <br />1123 West Second Grand Island, Nebraska, 68801-5899 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR lal. (b). AND 1011 <br />PART DIV ' <br />lel v tnNxti A <br />Interval between onset and death <br />tl' <br />DUE TO, OR AS A CONSEQUENCE F:, ff <br />(b) ����D tie,g4....) <br />Interval between onset and death <br />% <br />DUE TO. OR AS A SEQUENCE -OF, <br />(c) <br />Intervetbetwwean onset and death <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART CA <br />w �� <br />PART III IF FEMALE WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />_ (Ages 10.54) Yes n No ❑ <br />24. AUTOPSY <br />1.�/Is <br />Yes n No 1 7U <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONERII '!( <br />Yes n No pp4 <br />26a. <br />II Accident III Undetermined <br />II Suicide • Pending <br />II Homicide Investigation <br />26b. DATE OF INJURY (Mo.. Day, Yr.) <br />280. HOUR OF INJURY <br />IA <br />26d. DESCRIBE HOW INJURY OCCURRED Y <br />We. INJURY AT WORK <br />Yes ❑ No ❑ <br />ho <br />26f. - t Waiter , farm.st street factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />z <br />$ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />5/L1/ 3- <br />g <br />28a DATE SIGNED (Me.. Day. Yr.) <br />28b. TIME OF DEATH <br />M <br />27b. DATE SIGNED (Ab.. Day. Yr.) <br />Sl2.111t <br />270. TIME OFF DEATH <br />C10 33 M <br />i <br />8 <br />28c. PRONOUNCED DEAD (eau. Day YrJ <br />28d. PRONOUNCED DEAD (Few) <br />M <br />time, date and place and due the <br />27d. To the best at my knowledge. death occurred at the10 <br />cause(s) stated. a/tl".{ it 1-_ <br />n <br />(Sigore and Title) II. <br />§ <br />is <br />28e. On the basis of examination and/or investigation. in my opinion death occurred at <br />' the time, dale and place and due to the vessels stated. <br />(Signature and Tale) ► . <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ YES RI I NO ❑ UNKNOWN <br />30.e HAS ORGAN OR TISSUE DONATION B CONSIDERED? <br />❑ YES NO <br />305 WAS CONSENT GRANTED? <br />❑ YES 'tel NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (rype or Print) <br />Dr. Anne K. Morse, 729 . Custer Av , nd Island, Nebraska 68803 <br />3/2a REGISTRAR <br />J/ • <br />32b. DATE FILED BY_ gEOISTRA_R ( Yr.) <br />JUN 6 IYVrM/� <br />