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<br />( / STATE OF NEBRASKA
<br />.< U/111J11fu.:.:-ri :, Tn,44VMS �4�fNiifNf)J;.::
<br />R> E II$ED SEAL OF STATE OF NEBRASKA, IT'CERTIFIES THE DOCUMENT
<br />OtICalitAL RECORD ON RILE WITH THE NEBRASKA DEPARTMENT OF HEALTH
<br />itAt REC"ORBS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202S06988
<br />ICA
<br />SARAH BOHNEN
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HE
<br />AND HUMAN SERY1I`
<br />TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE 9F>REATH
<br />st, Suffix)
<br />WON COUNTRY OF BIRTH
<br />tTl. (I$ ibt Ztp Code)
<br />1f)+Et&TAt 1 IEttli lj5ti
<br />90.'NI$AcialN Way
<br />d number)
<br />b. COUNTY
<br />Hall
<br />TA ,I i R7 rilMIF.QF,DEetl H ] Married 0 Never Married
<br />4tsep�fttald' [ Widowed ' ❑ Divorced 0 Unknown
<br />Last, Suffix)
<br />s of service If Yes.
<br />8181 /1962
<br />5a. AGE Last'airdtday
<br />(Yrs.)
<br />. UNDER 1 YEAR
<br />9a< #tLAC E OF t2EA'i'H
<br />HOSPITAL ❑'inpatient
<br />0 ER/Outpatlent
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />OTHER ❑ Nursing
<br />® Decedent
<br />❑ oe'tsr tarp
<br />Ilid. COUNTY OF DEATH
<br />Hall
<br />M. APT. NO.
<br />9f. ZIP COPE
<br />68803
<br />lob. NAME OF SPOUSE (First, Middle, , Last, Suffix) (f wife,
<br />Gay Ellen Barth
<br />12. MOTHER'S -NAME (First, Middle, Mal
<br />Opal K Sterry
<br />14a. INFORMANT -NAME
<br />Gay Ellen Boardman
<br />9ALMERSIONATURE
<br />than S. Santin
<br />:EMETERY, CREMATORY OR OTHER LOCATION
<br />Berton Cemetery/
<br />!N1ti;fiG41(IE!(N0 MAILING ADDRESS (Street, City or Town, State)
<br />iIn u: it I Hs t t;'210 Irving Street, PO Box 851, Fullerton, Nebraska
<br />6b. LICENSE NO.
<br />1466 ,
<br />CITY / TOWN
<br />Fullerton
<br />CAUSE OF DEATH (See Instructions and examales)
<br />s�Ilasrtr injuries, or complications -that directly caused the death. DO NOT enter terminal twins such as cardiac arrest,
<br />dhifon widM1A showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Tine. Add additional lines if necessary,
<br />OI�►tE CAUSE:
<br />ttrro ca"ricer
<br />A CONSEQUENCE OF:
<br />RASA CONSEQUENCE OF:
<br />{
<br />A CONSEQUENCE OF:
<br />+Ati*T.tt C}ii#EII: StCiifIF1 } i"r0ND1710NS-Conditions contributing to the death but noting in the underlying cause di en In P
<br />t dtdidfie, nid pi rf ndrpi te, non'Hodgkin lymphoma, chronic obstructive pulmonary disease, hypertension
<br />21a. MANNER OF.DEATH'
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />I Suicide ❑ Could not be determined
<br />re death
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY.ftt ho
<br />RISE HOW INJURY OCCURRED
<br />21b. IF TRANSPORTATION INJURY
<br />0 Dilver/Operetor
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />let, factory, office build)
<br />I OCA ION4?P;:Pf3LT1( i'..swe , NUMBER, APT.NO. CITY/TOWN STATE
<br />Day, Yr,
<br />23c. TIME OF DEATH
<br />01:17 AM
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ONOUNCED DEAD (Mo., Day, Yr
<br />rT*tlia: to#�(ly;klt+%rA.eil)•�death occurred at the time, date and place y�
<br />iil lee, On the basis of examination anNor htveetgattan
<br />' tld iluti ip.ttii;i fre$ l*tl(ed.{Signe*ure and rni•) thefts, date and place and due to the caues(s)
<br />;>OiS1►E Q;4 ;C!ptE fhUI t it11SDEATH? 26a. HAS ORGANOR 'tissue DONA'DONSEEN CONSIDERED? 2Sb.WAEO
<br />PROffABLY ® UNKNOWN 0 YES ® NO Not Appuoabln
<br />I. itltTi,' iq Ed OI?A R71FtER(TypeorPrint .
<br />Oil l ; 4t l 11' I'Fai41l, Box 9802, Grand Island, Nebraska, 68803
<br />F) A A"1DR ',; 26b. DATE FILE
<br />Q % y� ,e7 V
<br />August 5;
<br />
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