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' c7 ��a C� � <br /> W �"- } � f ' <br /> �:� <br /> � � � � v � 4 0 <br /> T <br /> g9_ it��o56 <br /> WHEN TFNS COPY CAIaRE3 TFE RAI3ED SEAL OF THE NEBRA3KA HEALTFI�AIl1 SER1�'lCES <br /> SYSTEII�IT CERT�S TtE BELOW TO BE A TRUE COPY OF THE ORIfiIN�!�E WITH <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEII�VITAL 3T��,W�UCH/S <br /> THE LEQAL DEPOSITORY FOR VITAL RECORD� __ - ' <br /> DATE OF ISSUANCE 1'i':_T�� <br /> MAR 3 1 1�99 �rt�r sT,���-�-_-�R <br /> UNCOLN,NEBRA3KA HEALTHA�Mf�f��S1�TEM <br /> STATE OF NEBRASKA-DEPAR'IMEN'f OF F�ALTH AND HUb[h�,S�����SUPPORT <br /> VITAL STAT[SI'ICS - , _ ' - <br /> . CERTIFICATE OF DEATH-`��-�:-��� - <br /> t DECEDENT-NAME FIRST MIDDLE IAST � 2.$Ex . .. � . �3 QATE OF DEATH lMOnlh Day Yearl <br /> Burton E Feaster Male March 23, 1999 <br /> a.CITV AND STATE OF BIRTH /ll nol in USA..neme coun(ryI Sa.AGE-Laaf Bmhtlay UNDER 1 VEAR UNDER�DAV 6.DATE OF BiRTH /MO.n(h Day Year1 <br /> York, Nebraska ���s.i 82 eo Mos i DAVS St.HOURS MINS M`dy IO, 1916 <br /> 7.SOCIAL SECUFlTIV NUMBEA Ba.PLACE OF DEATH <br /> 507-03-4672 HOSPITAL � Inpa�i0n� OTHER ❑ Nu�Sing Home <br /> , -- - <br /> 8b.FACIUTV-Name l���OI rn5MUh0/1.9iVB SbBBI dnd numbB// Q EA OulpatieM � RevOence <br /> � St. Francis Medical Center ❑ �^ ❑ a���so��H� <br /> 8c C�T'/TOM�N 0 LOCATION OF DEATH Btl WSIDE CITY�IMITS Be COUNTV OF DEATH <br /> Grand Island v.5 �C] ra ❑ Hall <br /> 9a.RES�DENCE-S7ATE 9E.COUNTV 9c.CITY.TOWN OR LOCATION 9d.STREET AND NUMBER llnGudiiqZOCodel 9e INS�DE CITV LIMITS <br /> Nebraska Hall Grand Island 1819 West Division, 68803 v,��] No� <br /> 10.RACE�le.g..W�ite.Black.American kWian 11.ANCESTRV le.g..Mali�n.Mecican,Gaman.elcl 12.�MAfiRIED ❑WIOOWED 13 NAME OF SPOUSE /ll wAe.gne ma�Cen nameJ <br /> W�IILC NI American MEVER DIVORCED p <br /> Irene Thom son <br /> 1<a.USUAL OCCUPATION IGrve kind ol work done during mosl 1 aD.KIND OF BUSINESS INDUSTRV t 5.EDUCATION ISpec�ly only nighes�graCe completed� <br /> ol work�ng lile,even il iehredl Ebm;r�jdry o�SeconOary 10��2� Collppe n�a o�5•i <br /> Teacher Teaching i� y <br /> 16 FATHER-NAME FIFST MIDDIE UST 17.MOTHER FIRS7 MIpDLE MAIDEN SURNAME <br /> Wilbur Feaster � Grace Foster <br /> 10.WAS DECEASED EVER iN US.ARMEI�FORCES? �(�OZII94Z-- t9a.INFORMANT-NAME <br /> Ives�o.o�onk.l P��es grve w;-arb aates of sarvices <br /> Yes Worlcl 1:'ar I[ I(."J7i1945 � Irene V. Feaster _ <br /> 19� MFORMANT MAILW3 ADDRESS fST.REET OR F.FD.NO..CITV OR TOWN.STATE.ZIP: <br /> 1819 West Division, Grand Island, Nebraska 68803 <br /> 20.EMBAL fi�SIGNlysUHE 8 4 ENSf n0. 21a METHOOOFDISPOSITION 21C.GATE I 21t CEMETERV OR CREMA70WV�NAME <br /> �/ � ��. �/Z/� �Bunal �Aemoval 03/27/1999 ' Greenwood Cemetery <br /> 22a FUNERAL HO �NAME 21tl.CEMETERV OA CREMATOAY LOCATION CITV OA 7p�rVN STATE <br /> Apfel-Butler-Geddes Funeral Home I ❑a�a�� ❑o��a�b� York,Nebraska _ __ <br /> 2ffi.FUNERAL NOME ADDRESS IS7REET OR R.F.D.NO_CITV OA TOWN.STATE,ZIP� <br /> 1123 West Secoud Grand Island,Nebraska,68801-5899 <br /> 23. iMMEDIATE CAUSE IENTER ONLV ONE CAUSE PER UNE FOR lal.IDI.AND�c11 � �ntervai between onset and deain <br /> PART A � ��'� � � ��� <br /> � lai /l _ <br /> DUE 70,OR AS A CONSEOUENCE OF � Intervai benveen onsei and deain <br /> �ei ��� l�1/(1C�Y'C.. _ - � �Y'7�� <br /> DUE TO.OR AS A CON�E.�'.UFNCE(�� ' ��:w�a�oetween Oreel antl tlealh <br /> I�I � <br /> OTHER SIGNIFICANT CONDITIONS�ConGdions coMribWing to IM dsat�Dul not ralated PART III IF FEMALE.WAS THERE A 2a AUTOPSV 25.WAS CASE REFERRED TO MEDICAI <br /> PART PREGNANCV IN THE PAST 3 MONTHS° EXAMINER OR CORONER� <br /> II <br /> �Ages i0-Sa� Yas No Ves No Ves No, <br /> 26a 26c� DATE OF INJURV /MO.Dey YrJ 26c.HOUR OF INJURV 280.DESCRiBE HOW INJURY pCCURFED <br /> � Acndent � Undetermine0 M <br /> � Su�oae � Pend�ng 26e �NJUA�AT WORK 28�.PLACE QF,INJUFV-pt ho�y,larm.street.lactory 26g LOCATION S7REET OR RFD NO GTY OR TOWN STA7E <br /> ❑ O ❑ ofFca bu aup.stc. lSpecny/ <br /> Hom�ude ImesugaUOn Yes No <br /> 27a DATE OF DEATH (MO Day v�l 28a DATE SIGNED IMO.Dav Y�1 28b TiME Of DEATH <br /> z / ��� " y.g i M <br /> �`3, 27D DATE SIGNED /MO Day Yrl 27a TIME OF DEATH `��'� 28c.PRONOUNCED DEAC lMO..Day.Yr.l 280.PRONOUNCED DEAD (HOUn <br /> ��� � - y- 9 ��: �� � N= M <br /> M �¢�� <br /> g� Pt <br /> Do To me Eest o my knowl .tlea acurre0`at t�e m dat ntl nd due io the � 28e.On�he bas�s of ezamination antl�or mvesugauon,m my opimon tleath acurreG a� <br /> causelsl s�aled. � � u a t0e time,tlale antl place antl tlue to the causelsl slated. <br /> I5�nature and Tnla ► �S�nature an0 Title <br /> 29 DID 708ACC0 USE CONTRIBU7E TO THE DEATH? 30.e HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSEN7 GRANTED� <br /> � VES � � UNKNOWN � YES I\`1�N0 � �ES �MO <br /> .��� <br /> 37 NAME AND ADDfiESS OF CERTIFIER IPHVSICIAN,CORONER'S PHYSICIAN OR COUNN ATTORNEYI lType a Prinll <br /> Dr. David R. Colan,729 N Custer,Grand Island, l�lebras a 68803 <br /> 32a REGiS7RAR �i � ,� 32D.DATE FILED Bv REGiSTRAR (MO..Oay n./ <br /> '1� ,� <br /> � L�W�:wY. � <br /> �. Gt- �� l3la� K ��, ctia� c�s �tis� c� �. dd;-t�� � <br />