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<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASI{A�»£�,TATE
<br /> DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRtJrE 'COPY
<br /> OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPAiiT1�FNT OF HEA�,,�H
<br /> BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DE�dSITORY �'OR ;
<br /> VITAL RECORDS. � '
<br /> w;
<br /> ._�
<br /> DATE OF ISSUANCE
<br /> AUG 1 81987 STANLEY S. C��IA�R, DT�,�C�OR
<br /> , ., ,• .. .�. _
<br /> LINCOLN, NEBRASKA BUREAU OF VITAI:�'�T$t�3S1`ICS
<br /> STATE Of MEBRASKA-DEPARTMENT OF NEALTFI
<br /> BUREAU OF VITAL STATISTICS
<br /> CERTIFICATE Of DEATH P.��-� __ __
<br /> OEGEDENT-NAME fIRST MIDDIE UST SE; DATE OF DEATM(MO,Do�.Y.1
<br /> -Allan Charles Pa ne � Sr• 2 •�ale 'LAu t 2 1�7- �- --- --_ ---
<br /> i. --
<br /> fACE-(�.y.,Whir�,llock,Aiw�r�can ORIGIN/DESCEN7(�.y.,irolion,M�Ricon, �GE-to.���ni.dor UNDER 1 YEAR UNDER 1 DAt D�TE Of 6iR�N(Mo.,Do�,v�)
<br /> Indion.�k./(Sp�ci/y/ Gn1nan.�tc.)ISp�cil�l /Y.t.) MOS. • DA�S' NOURS�MINS
<br /> � White s. American ,, 56 eb ; la� � Sep 15, 1930 __
<br /> ITY ANO STATE Of SIRTM(N ne1 in U.S.A., CITIZFN Of WMA�COUNTRY MAR�IED,NEVER MARRIED, I NAME Of 5►OUSE(1l.il�,yi.�moid�n naiw�l
<br /> wa�counn � w100wED,DiVORCED(Sp•ulrl !
<br /> e.NORTI� PLATTE,NEBRASKA 9 U.S.A. ,o Married I„Ladonna Spencer _
<br /> SOCIAI SECURITY NUM6ER USUAI OCCUiAT10N(Gir�kind e/ror�don�during�no�� KIND OF lU51NE55 O�INDUSTRY C—T OUNTY Of DEATH
<br /> o!w �n 1�/ �r n i! •lir�d)
<br /> ,2. 506 26 2854 ,�,�r�ick. �r�ver 11b G.I. Express „a D�$as _ __
<br /> CITY,TOWN OR LOCATION Of DEA1M INSIDE CIT/LIMITS HOSIITAI OR OTME�INSTITUTION-Namt (II nor�n�dA�r, �Ii MOS► OII iNSt i�d�m�•DO/..
<br /> (SP�rifyY��o�No/ y�•��r.�d and nu�wb�rl O�rpo���nr/E�. Rw�.I�poe�n��Scw.I�i
<br /> ,�b Omaha ,k Yes „d.VA Medical Center �.. In atient
<br /> IIESIDENCE-STATE COUNTY CtTY,TOWN OR tOCATION STREET ANC NUMlEII INSIDE CITY IIMITS
<br /> 2920 West 17th St �rs�•�;rrr.,o.No;
<br /> ,S,.Nebraska ,sb. Hall ,xGrand Island �sa. i�s. Yes__
<br /> fAiMER-NAME fIR T MIDDIE US' MOiMER-MAIDENNAME fIRST MIDDIE LAST�
<br /> ' 16 Andy Payne ,,. Tilda Mar�_ Johnson _
<br /> �. WAS DECEASED EVER IN U.S.ARMEO FORCESt INfORMANT-NAME-RElAT10NSMii��-MAIUNG ADDRESS tSrteEr OR6t,[QOQ.ui'�O�TowH Sr�re tm
<br /> cr.,.�o.o,�„u�u�y...y�..�o.o„e �..e��...�<.i ZStf 3
<br /> 1e Yes � 11-22-50,3-31-71 ',Si,aDonna Pa ne: Wife: 2920 W. 17 St.� Grand Island� Ne
<br /> , BURIAL,Cremation,R�movol DAiE CEMETER�OR CREMATO�Y-NAME i IOCATION CITY OR TOWN STATE
<br /> z� Burial �August 5, 198 j�Grand Island City ��� Grand Island, Nebraska _
<br /> � EMlA !-SIGNAiURE�U ENSE NO. FUNER�I HOME-N�E�NO ADORE55 (ST�EfT OR f f D NO.C�n'O�TOWN.ST��E.Iiii
<br /> �a ��� �z�lpfel-Butler-Geddes 1123 W. 2nd: Grand Island, Ne 68801
<br /> 2� —
<br /> OATE Oi OEATN(Mo.,Do�,Yr.l DATE SIGNE�(Mo. Doy.Yr.) i MOUR Of DEATH
<br /> I ; August 2, t987 ;`_Z z.b. M
<br /> y 230. v" YIa. _
<br /> ',, g=r DA1E SIGNED(Mo.,Dar,Yr.) HOUR Of DEA1M i=C iRONOUNCED OEAD �RONOI�NCED DEAO(Mour)
<br /> `'� j�� (Me.Doy.Yr.) . . ._. _ ._ .. . ___ .._.
<br /> 3i ,� Au�ust 3, 1987 ,23 10:37 A � l�W=�•:u --�zae M
<br /> f� i�IM bn1 0�1+y Ynwl w�A xc�.nd e�rM 6 w an o�d pba•md du•�e r6• E D O �On M�bo�b o1 uos�nanw andlo.Inwu�ponen.in�wr op�n�en dwr6«<�n�d or
<br /> �, � aaw�4�ar�d. ��s� �rM n�,dar�and vlu�ond d��ro M�muw(�1 No��d
<br /> .t ( �e
<br /> � Z�d.(Siyno�rn and f�M� Q.wt,lt�
<br /> � I j4�.(Sqnorvn end hM�).
<br /> �� NAME AND ADWESS OF CERTI R iMY51CIAN,CORONER'S PMYSKIAN OR COUNTY ATTORNEY)(I�p�or Vrinl)
<br /> ' JAMES HANSEN, .D. , VA MEDICAL CENTER, 4101 Woolworth Ave. , Omaha, NE 68105 _
<br /> tEGISTRA� f OATE REAU�!Y R�I�o.,Doy,Yr.)
<br /> I ,.�[� , ��' - � ,!•�'
<br /> 26a.lS;y�oru.�l� , 266.
<br /> 7. IMMEDIATE CAUSE N1ER ONIY ONE CAU IEf UNE fOR(01,(b),A D(�)) � ��r•�.el on..•�n on..�o+d dwrb
<br /> �ART �
<br /> �,, Pneumonia � 2 weeks
<br /> DUE TO,O�AS A CONSEOUENCE OF: � �ear.a�b�r..•«�o��o�d dwr�
<br /> ,,, Small cell carcinoma of lung � months
<br /> DUE TO,OR AS A CONSEOUENCE Of: � ��ti.w�b.tio�on.a a�d dw1A
<br /> (d
<br /> ►ART NE�SIGMM1CANi CONOITIONS-C�ndi�i�n�conhibu��np ro dwM brr ne�r�leNd ►ART III.11 fEMAIE.M�AS TME�E A AUiO�SY M�AS CASE�EfERREO i0 MEDICAI
<br /> �REGNANC'I IM TNE►AST�MONiMSi (Sp�<i!�Yti e.No1 EllAMINE�Ot COWNt�
<br /> () (SpK�ti rti o.we�
<br /> r.�O No C se �v.
<br /> •CCiDE►ri,SUKIOt.NOMIC�OE.U�+Ot1, p�TE O►INJUt�(�.,De�,Yr.l MOUR p IN1U�1' DESCM�E NOW 1WU�1'OCCU��EO
<br /> W►lMpNG INVlSTIGATION.(S�ilr)
<br /> �Oo. �Ob. �Oc. M 30d.
<br /> IN1Wt AT WOtlI ►lAC!d I►UURt-A/Mww.lor�.Mr�N.beNry. IOCATION STltlT O!l.f.0.1N. CITIr O�fOWN STAT!
<br /> (sn«+h r««w� .N;�.r.as:M..k.!sv«+M�
<br /> 70.. �.
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