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S <br /> NMEN TI�S COPYCARRIES THE RA/SED SEAL OF THE NEBRASKA HEALTH � � �CES Q <br /> SYSTEIY�IT CERT/F�S TF�BELOW TO BE A TRUE COPY OF THE OR10/NA - 6�i9!���H <br /> THE NEBRASKA HEALTHAND HUMAN SERVICES SYSTEM,VITAL STAT(�I��S�11,_B� <br /> THE LEGAL DEPOS/TORY FOR VITAL RECORDS = -_ ' -�-'= = <br /> DATE OF/SSUANCE - �� ' <br /> OCT 2 31998 ��s- i°'"���0�� � <br /> �ASS�Al1�S,�`/ITER�h� ,. <br /> L/NCOLN,NEBRASKA HEALTH A�ID H�ifA�Y3T.FJi+1 <br /> STATE OF NEBRASKA-DEPAlt'IMENf OF HEALTH AND HUMAN SEAi�f�FfDh►I�IC��PPORT <br />, V1TAL STATISTlCS �=:���:" <br /> CERTIFICATE OF DEATH � <br /> 1.DECEDENT-NAME FIRST MIDDIE UST 2.SEX�� � 3.DATE OF DEATH /AbnM.Day.Yw/ <br /> John Raymond Alexander Male September 21, 1998 <br /> �.CRV AND STATE OF BIRTN IMrp/ir U.S.A..rwms cqiMry) Sa.AQE-Lul&ahday UNOER 1 VEAR UNDER 1 OAV 6.DATE OF&FTM /MpM��.D�y.Yqq <br /> Grand Island Nebraska ��n.� 83 so.Mos. o�vs x.Houas� M�NS. September 02, 1915 <br /> Z SOCULL SECURTIV NUMBER B�.PUCE OF DEATM <br /> 506-09-7410 HOSPITAL: � Inp�N�A OTHER: � Nwsinq Hans <br /> lD.FACRRV-Nuns /MnnfMtMNNOn.Ohtia4N��nCrmM�r/ '-- � EROu1ptlNM � Rn�tlsnc� <br /> Lakeview Nursing Center ❑ oa� ❑ om«isw��, <br /> �&.CITV.TOWN OR LOCATION OF DEATH � 8d.INSIDE CfTV LIMRS 8�.COUNTV OF DEATN � <br /> Grand Islan� • �„ � �, �] Hatl <br /> 9a.RESIOENCE-STATE 9b.CWNTV 9c.CITY.TOWN OR LOCATION Yd.STREET AND NUMBER /NIeApWpZ'p COds1 9e.INSIDE CRY LIMITS <br /> Nebraska Hall Grand Island 104 East 14th,68801 �,.� ,,,� <br /> t0.;NMCE•I�Y�.�e.�k.Amsric�n InOien. 11.ANCESTRV Is.q..MaMVt I.Nxian.(iurm�n,etc) 12 Q1 MARPoED ❑WIOOYVED 13.NAME OF SPOUSE /p wN.pw m��ayn n�/ � <br /> �.Eii4e' A�`ie"'rican �''N�ER avo�cEO Irene Scheibe <br /> '� 1k USUALOCCUPATpN (Givsk6qd»akdonsdurinpmqtl 11D.KINDOFDUSINESSINDUSTRV � , 15.EDUCATION (Spaify prWSeompNNO� <br /> �� di�arti�gNla,�wnilnlwMl E aSKOiW�ryl0.t21 � CaNq�n.�a5•i <br /> ; Power Plant Operator City of Grand Island ""�" <br /> 1!.FATM9i-NAME FIRST MIDOLE UST � �17.MOTHER FIRST MIDOIE MAIDEN SURNAME <br /> John Alexander Clara Phelps <br /> 1t WAS OQEASED EVER IN U.S.ARMED FORCES9 19a.INPORMANT-NAME <br /> (Yw.ro.a unk.� IN yes.q�ve wer and Aetas d eNVicss) � . <br /> No ( Irene Alexander <br /> 1l0.INFORMANT MAILING ADDRESS ISTHEET OR R.F.D.NO..CIN OR TOWN.STATE.ZIPI <br /> 104 East 14th,Grand Island,Nebraska 68801 <br /> lq. R-SIGNATUR�LICENS O. 21a.METHODOF dSPOSIT10N 21C.DATE 21C CEMETERI'OR CREMATORY�NAME <br /> / , �]B,„;,, �,�,,,o�„ 09/24/1998 Grand Island Cit Cemeter <br /> 22�.FUNERAI MOME- ME P1E.CEMETERV OR CHEMATORV IOCAT1pN CITV OH TON7J STATE <br /> Apfel-Butler-Geddes Funeral Home ❑��«� ❑��� Grand Island Nebraska <br /> YlO.FUNERAL HOME ADDRESS ISTREET OR R.F.D.NO..CITY OR TOWN.STATE.21P� <br /> 1 WestSecond Grand Island,Nebraska,68801-5899 <br /> IMMEDIATE CAUSE �ENTER ONLV ONE CAUSE PER LINE FOR Ia1.1�1.AND(c�l �� Inbrval bMw�en onfM anA Oealn <br /> I <br /> I <br /> � r � <br /> TO.OR AS A . � � nw�vai oNwMn ome�ane eeam <br /> . � ,. . . . . � I <br /> roi � �Z°GJ�'j <br /> � <br /> DVE TG.OR AS A SE UENCE OF: • � 1 ervai belween onae�aM deam <br /> I <br /> I <br /> ��� <br /> .�QIIER SIGNIFICANT CONDITIpNS-Candipons cmhidtinp b the CseM but nd rslateE PART III IF FEMALE.WAS THEfiE A AUTOPSV AS CASE REFERRED TO MEDICAL <br /> PREGNANCY IN THE PAST 3 MONTHS? E AMINER OR CORONEH? <br /> � <br /> �Ages t0-51) Ven No Ves �NO Yn No <br /> 2N. � Z6b.DATE OF INJURY /MO..Day.Ytl 26a HOUR OF INJURV 26E.DESCRtBE NOW INJURV OCCUHRED <br /> � AccWent � Und9termined M <br /> � Suitida � PerWing 28e.INJUiiV AT WpRK 261.PLAC�OF.�JURV�{U hoR�g.hrm.strset.latbry 26g.LOCATION STREET OR R.F.D.NO. qTV OR TpWN STATE <br /> O ❑ olfce w10� etc SP�M/ <br /> � Honucitle Invesigalion Veg p�p <br /> 27a.DATE OF DEATH /MO..Oay.Yr.J 28a.DATE SIGNED (MO..Day.Y�.I 28b TIME OF DEATN <br /> a SEPTEMBER 21 1998 �<X' M <br /> .DATE SIGNED /Mn..Day.Yri � 27c TIME OF DEATM �� 28t.PRONOUNCED DEAD lMO..Diy,Yt) 2Bd.PRpNpUNCED DEAD fFbwl <br /> 8 �t �a <br /> _ � 10:45 AM 8" � M <br /> �� 7o Ms my krawNtlge.tls oceunstl q tl»tlrtr.dw arW Wacs and due to tha 3�� 28s.On px besis W�Y�minatbn an0�a�vw�tiqtlbn.in my opinbn tlseth oecurnA�t <br /> es 8)atsrod. �+ the Nms.MN end W+��sntl Ew b�Iw eupNq sqNd. <br /> Si naun and ritls Si naturs anE Tiqs <br /> TOBACCO USE CONTRIBUT TO E EATH7 � N AN OR TISSUE DONATION BEEN CONSIDERED7 WAS CONSENT GMNTED? <br /> IJ�I VES � NO � UNKNOWN � VES �NO ,'-- � VES IXI NO <br /> f__.. �._..� y�.,I <br /> 31.NAME AND ADDRESS OF CERTIFIER IPHVSICIAN,CORONERB PMVSICIAN OR CAUNTV ATTORNEYI /Typ�a Priny � � <br /> Dr.Thomas F.Werner,2444 W.Faid ey Ave.,Gran Island,Nebraska 68803 <br /> �.REOISTRAR 32p.DATE FILED B �/AQ.��� <br /> � <br /> ;�'� � r�.� -�s�' : � _. � �-.�- - <br />