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LOT 177, BUENAVISTA SUBDIVISION, CITY OF GRAM ISLAND, HALL COUNTY, NEBRASKA.
<br />WHEN THIS COPY CARRES TTE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM(, RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RNECO-RI ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA I3
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />FEB 2 7 2004 200402238 =Ass ER
<br />LINCOLN, NEBRASKA HEALTH AND-HUMANSERVICE&*ftTEb/'
<br />STATE OF NEBRASKA - DUAffrMENT OF HMTIT - 2 02041
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH :�,I- - -
<br />7. DECEDENT -NAME FIRST MIDDLE LAST '2. SEX 3. DATE OF DEATH (A ORA DW VON)
<br />Francis Dennis Struble Male February 12, 1992
<br />•. CITY AND STATE OF BIRTH INrw on U.SA., no" Country/ 58. AGE • LJW BWIWay 6. DATE OF BIRTH gllaww Deg, ya"
<br />M
<br />7. SOCIAL SECURITY NUMBER M. PLACE OF DEATH
<br />HOSPITAL ° MPAWO C ER OuoMeM o DOA
<br />707 -07 -7890 OTHER
<br />XXNursm9 Moms O Reerdertce ❑ Oata (SpW*1
<br />M. FACILITY - Narro (I na Jrraawian. gM strew aw nanaq 8C. CITY. TOWN OR LOCATION OF DEATH 8A. BMSIDE CITY L.BITS 8s. COUNTY OF DEATH
<br />lSpecdy Yee a NoJ
<br />Good Samaritan Center Wood River Yes Hall
<br />9e. RESIDENCE •STATE 9b. COUNTY 9t. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /kr xbV Zq C " M. tIMBMr CITY LIMITS
<br />/ %wC* Yes or AIN
<br />Nebraska Hall Grand Island 423 E. Nebraska Ave. Yes
<br />10. RACE - {e.g.. While. Week Amenean h-4w. 11. ANCESTRY (9.9..k0W. MMcican. German. Me.) 12. MARMM.NEVER MARRIED. 13. NAME OF pr My �yM Arty
<br />oft.) (SP-*) (SPSc*
<br />_
<br />tea. USUAL OCCUPATION (GM OW of V"* Apes dwM prat
<br />1eb. KIND OF BUSINESS INDUSTRY
<br />of waking N& ewn Brebw) � �
<br />Transport Driver
<br />j
<br />Transportation
<br />'py 18- CW
<br />v SM
<br />2
<br />18. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER - MAIDEN NAME FIRST MIDDLE - LJ18T
<br />Fred D. Struble I I I Anna C. Blown
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN, STATE, 2TPJ
<br />(Yee. no. a uNcl (M yea, 9iw wa aW daa a Mrmep)
<br />Yes: 11- 26-43 11 -27-45 era A. Struble -423 E. Nebraska Ave. - .Grand[ IM'NE
<br />2ft BURIAL. CnrneapnPwaval. 28b. DATE 20e. CEMETERY GA CREMATORY - NAME 20A. LOCATION CITY OR TOWN STATE
<br />Bur'al LFeb. 14, 1992 Westlawn Memorial Park Grand Island, NE.
<br />21.E - SIGNATU BE ^ } 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CRY OR TOWN, STATE, Z"
<br />f�''J/ fel- Butler- Geddes 1:23 W. 2nd, Grand Island, w.6g80
<br />Z
<br />I (A) 7--r,, C.4 I A & t , L Ldd-r S
<br />DUE TO. OR AS A CONSEQUENCE OF r aeYesl tleesseu oaeM was eeau
<br />i
<br />N
<br />a
<br />s
<br />my
<br />25. WAS CASE R� TO N O
<br />o
<br />�
<br />- y a �
<br />�
<br />o
<br />� �
<br />y
<br />28i ACCIDENT, SUIGDE. HOMICIDE, UNDET..
<br />OR PENDING INVESTIGATION 1
<br />286. DATE OF %UURV 1W.Day. Yr.)
<br />. HOUR OF INJURY
<br />26d. DESCRIBE NOW INAIRY OCCURRED
<br />N
<br />y
<br />28e. INJURY AIrWORK
<br />(Speedy Yoe or No)
<br />281. PLACE OF NAJRY - At home, tam. Wut taaay,
<br />aMCe WAdm9. oft. JSP-*)
<br />M
<br />�
<br />m
<br />o
<br />28a. DATE SIGNED IW_ Vey, yr.)
<br />28b. THE OF DEATH
<br />C)�
<br />27U DATE SIGNED (W. Dry, yrl
<br />cJD
<br />� z
<br />286 PRONOUNCED DEAD
<br />�eoeW
<br />T IT3
<br />(13
<br />3 ¢
<br />To b of OL(
<br />27A. To Ile beet d my kbtiledpe e 10ew
<br />)v
<br />26e. On Ole basis a eeanwtaeon w&or nwY9ebn• m my opmron ditlh Donned a
<br />�00*tdale
<br />g b
<br />the tune. Mae OW Waee W A+s q 8le cawNs) e4leA.
<br />D
<br />n
<br />anA TWe
<br />29a. DID TOBACCO USE CONTRIBUTE fO THE DEATH? 30s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30b. WAS CONSENT GRANTED?
<br />0 YES C VO O UNKNOWN O YES '6' D YES Wb
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONEFrS PHYSICAN OR COUNTY ATTORNEr /Typ w -w -- - --
<br />David J. Colan S.D, 729 N. Custer, G- ?r_d 1 NE.
<br />-stand, 68803
<br />32a. REGISTRAR 6
<br />•
<br />32D. DATE FIL
<br />VX
<br />^�
<br />0
<br />Cn
<br />LOT 177, BUENAVISTA SUBDIVISION, CITY OF GRAM ISLAND, HALL COUNTY, NEBRASKA.
<br />WHEN THIS COPY CARRES TTE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM(, RCERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RNECO-RI ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA I3
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />FEB 2 7 2004 200402238 =Ass ER
<br />LINCOLN, NEBRASKA HEALTH AND-HUMANSERVICE&*ftTEb/'
<br />STATE OF NEBRASKA - DUAffrMENT OF HMTIT - 2 02041
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH :�,I- - -
<br />7. DECEDENT -NAME FIRST MIDDLE LAST '2. SEX 3. DATE OF DEATH (A ORA DW VON)
<br />Francis Dennis Struble Male February 12, 1992
<br />•. CITY AND STATE OF BIRTH INrw on U.SA., no" Country/ 58. AGE • LJW BWIWay 6. DATE OF BIRTH gllaww Deg, ya"
<br />(Yrs.i 5b. MOS. I DAYS 1. HOURS( MINS.
<br />Alliance, Nebraska 83 July 101 1908
<br />7. SOCIAL SECURITY NUMBER M. PLACE OF DEATH
<br />HOSPITAL ° MPAWO C ER OuoMeM o DOA
<br />707 -07 -7890 OTHER
<br />XXNursm9 Moms O Reerdertce ❑ Oata (SpW*1
<br />M. FACILITY - Narro (I na Jrraawian. gM strew aw nanaq 8C. CITY. TOWN OR LOCATION OF DEATH 8A. BMSIDE CITY L.BITS 8s. COUNTY OF DEATH
<br />lSpecdy Yee a NoJ
<br />Good Samaritan Center Wood River Yes Hall
<br />9e. RESIDENCE •STATE 9b. COUNTY 9t. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /kr xbV Zq C " M. tIMBMr CITY LIMITS
<br />/ %wC* Yes or AIN
<br />Nebraska Hall Grand Island 423 E. Nebraska Ave. Yes
<br />10. RACE - {e.g.. While. Week Amenean h-4w. 11. ANCESTRY (9.9..k0W. MMcican. German. Me.) 12. MARMM.NEVER MARRIED. 13. NAME OF pr My �yM Arty
<br />oft.) (SP-*) (SPSc*
<br />ji W9)OLYEO.DIVORCED /Spsey/
<br />White American �06 Married Vera A. Tockey
<br />tea. USUAL OCCUPATION (GM OW of V"* Apes dwM prat
<br />1eb. KIND OF BUSINESS INDUSTRY
<br />of waking N& ewn Brebw) � �
<br />Transport Driver
<br />j
<br />Transportation
<br />'py 18- CW
<br />v SM
<br />2
<br />18. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER - MAIDEN NAME FIRST MIDDLE - LJ18T
<br />Fred D. Struble I I I Anna C. Blown
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN, STATE, 2TPJ
<br />(Yee. no. a uNcl (M yea, 9iw wa aW daa a Mrmep)
<br />Yes: 11- 26-43 11 -27-45 era A. Struble -423 E. Nebraska Ave. - .Grand[ IM'NE
<br />2ft BURIAL. CnrneapnPwaval. 28b. DATE 20e. CEMETERY GA CREMATORY - NAME 20A. LOCATION CITY OR TOWN STATE
<br />Bur'al LFeb. 14, 1992 Westlawn Memorial Park Grand Island, NE.
<br />21.E - SIGNATU BE ^ } 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CRY OR TOWN, STATE, Z"
<br />f�''J/ fel- Butler- Geddes 1:23 W. 2nd, Grand Island, w.6g80
<br />IVY - ART ENTER ONLY ONE CAUSE PER LIME FOR (al. (bl. AND (cl) f kllatwl baaeesa Mart aa/ rr,
<br />I (A) 7--r,, C.4 I A & t , L Ldd-r S
<br />DUE TO. OR AS A CONSEQUENCE OF r aeYesl tleesseu oaeM was eeau
<br />i
<br />DUE TO. OR AS A CONSEQUENCE OF: I trtlervsl beeeeen alert awe IeeIN
<br />I
<br />I
<br />PART OTHER SIGNIFICANT CONDITIONS - Conftons cwwft n9 to deelh bm not rNaled
<br />PART M IF FEMALE. WAS THERE A
<br />2e. AUTOPSY
<br />25. WAS CASE R� TO N O
<br />e •�
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />- y a �
<br />�
<br />.Ad
<br />Y• t /
<br />yes ❑ No ❑
<br />28i ACCIDENT, SUIGDE. HOMICIDE, UNDET..
<br />OR PENDING INVESTIGATION 1
<br />286. DATE OF %UURV 1W.Day. Yr.)
<br />. HOUR OF INJURY
<br />26d. DESCRIBE NOW INAIRY OCCURRED
<br />N
<br />28e. INJURY AIrWORK
<br />(Speedy Yoe or No)
<br />281. PLACE OF NAJRY - At home, tam. Wut taaay,
<br />aMCe WAdm9. oft. JSP-*)
<br />2%. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (ft.. Day. Yr.)
<br />28a. DATE SIGNED IW_ Vey, yr.)
<br />28b. THE OF DEATH
<br />27U DATE SIGNED (W. Dry, yrl
<br />27c. TIME OF DEATH
<br />26C. PRONOUNCED DEAD p►e6. Deg. Yr./
<br />286 PRONOUNCED DEAD
<br />�eoeW
<br />3 3
<br />3 ¢
<br />To b of OL(
<br />27A. To Ile beet d my kbtiledpe e 10ew
<br />)v
<br />26e. On Ole basis a eeanwtaeon w&or nwY9ebn• m my opmron ditlh Donned a
<br />�00*tdale
<br />g b
<br />the tune. Mae OW Waee W A+s q 8le cawNs) e4leA.
<br />Tde AJA
<br />anA TWe
<br />29a. DID TOBACCO USE CONTRIBUTE fO THE DEATH? 30s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30b. WAS CONSENT GRANTED?
<br />0 YES C VO O UNKNOWN O YES '6' D YES Wb
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONEFrS PHYSICAN OR COUNTY ATTORNEr /Typ w -w -- - --
<br />David J. Colan S.D, 729 N. Custer, G- ?r_d 1 NE.
<br />-stand, 68803
<br />32a. REGISTRAR 6
<br />•
<br />32D. DATE FIL
<br />VX
<br />
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