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�t �7 . , <br /> n � % p � _ • <br /> � _ � �,7 F ✓C �.7 {�+,� <br /> � O m T t;1 7 � � � � � <br /> � � �- � 1� � CD <br /> m � <br /> �i � o � Q -*t � c�' <br /> .,,� t--+ '�7 F.,� N <br /> w,�, N <br /> � � � � � f'� � � N <br /> � a � � � � � <br /> pp o '� - «' � v� <br /> � � H ..'`.. � <br /> � � <br /> � <br /> � Recorder's Memo: Lot 13, Block 9, in Boggs and Hill's Addition to the City of Grand Island, Hall County, <br /> � NE ar Lot 1, Block 1, Colonial Estates Subdivision to the City of Grand Island, Hall County, NE <br /> WHEN TH1S COPY CARRIES TF�RAISED 3EAL OF THE NEBRASKA HEALTH AND-HHMAN-SERVICES <br /> SYSTEII�IT CERT�S TFIE BELOW TO BE A TRUE COPY OF THE ORI(iINAL�O�i_F�MTFI <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STAT�L��j IS <br /> THE LEGAL DEPOS/TORY FOR VITAL RECORD3 =___ - � - "-- == <br /> DATE OF/SSUANCE �/� ��l'�`^= <br /> - = V L�!� _"'"�:=.- '_ <br /> APR 2 81999 ��'=` ����o� <br /> as��iyur sra re x�o►s� <br /> , UNCOLN,NEBRASKA HEALTH AND�/At�N¢�RVI�ES s°YST�dN <br /> S'fATE OF NEBRASKA-DEPARl'I�NT OF HF,ALTH AND HUMA�ERyj�ANp�pppRT <br /> V1TAL STATISl'ICS = -- --- -_ -_ <br /> CERTIFICATE OF DEATH"__� �--�-=- <br /> i.DECEDENT-NAME FIRST MIDDLE LAST �� 2.SEX --- 3.DATE OF DEATH tMOnrn Dav Yeail <br /> Phili Ra nd Downs Male A ril 22, 1999 <br /> 1.CI7V AND S7ATE OF BIRTH llI nof n USA..name tountry/ Sa.AGE�Lasl 8irthtlay UNDER 1 VEAR UNDEF 1 DAY 6.DATE OF BIRTH rMOnM.Day Year/ <br /> North Platte, Nebraska �v`S� 51 5D Mos oavs SC.'HOURS' MINS <br /> December 11 1947 <br /> 7.$OCIAL SECURTIY NUMBEF Ba.PLACE OF DEATH <br /> 505-68-2961 HOSPITAL � InDa�ieM OTHEF � Nursing Home <br /> !E.FACILITV-Name /Mrpf mslitufidt give slreei aM numdeQ � ER Outpatient � Resitlence <br /> 1224 Plantation Pl'ace ❑ °OA ❑ ahe�,s��,ty, <br /> R.CITV.TOWN Ofi LOCATION OF DEATH Btl.INSIDE CITY LIMITS Be.COUNTV OF DEATH - <br /> Grand Island �� � "° ❑ Hall <br /> 9a.RES�DENCE-$TATE 9b COUNTV 9[.CITY.TOWN OR LOCATION' 9d.STREET AND NUMBER �lncludingZpCoOe!�HSO3 �INSIDE CITV UMITS <br /> Nebraska Hall Grand Island 1224 Plantation Place `'85❑X "°❑ <br /> 10 RACE-�s.g.,While.&atk.Amerkan Intlian. 11.ANCESTRY le.g..I�alian.Mezican,German,etc� 12.�MARRIED ❑WIDOWED 13.NAME OF SPOUSE Ill wrk.give maiden name/ <br /> MC.I ISpec�lyl ISpealy� NEVER <br /> White American M DIVOFCED Michele Johnson <br /> 14.USUAL OCCUPATION /Give kind d work done tluring mos� 1 ab KIND Of BUSINESS INDUSTRY 15.EDUCATION �Speoy only n�ghest gratle completed� <br /> d wakmg/?e,even d rNNedl � Elementary w SesonOary 10-t 21 Cdlege Lt�4 or 5�i <br /> Teacher Education 12 5+ <br /> 16.FATMER-NAME FIRS7 MIDDLE LAST 17 MOTHER FIRST MIODLE MAIDEN$URNAME <br /> � <br /> Ra nd Downs Laura Peter�ohn <br /> 16 WAS DECEASED fVER IN U.S.MMED FORCES? 19a.INPORMANT-NAME <br /> IVas.no.or unk.� 111 yes.grve war anA dates al services) I <br /> No Michele Downs - Wife <br /> 1�JU.INfORMANT MAtLING ADvFESS IS7REET OR R.F D NO_CITV OR TOWN.$TATE.ZIP) - <br /> 22 Plantation Place, Grand Island, Nebraska 68803 <br /> 20.EMBAL R-SIGNATURE 8 UCENSE h0. 21a.ME7HOD OF DISPOSIT•ON 21b DATE 21c.CEMETERV OR CREMATORr �AME <br /> -� � Service <br /> 34 [�B�:a� �Removal A ril 26, 1999 Central Nebraska Cremation <br /> a.FUNERAL H E�NAME 21tl CEMETERV OR CREMA70RV LOCATION CITV OR TOWN STATE <br /> Q Cremafon �Donauon <br /> A fel-Butler-Geddes F.H. Granc3 Island Nebraska <br /> 22b.fUNERAL HOME ADDRESS ISIHEET OR RF.D.NO.Cliv Of7 TOWN.STATE.ZIP� -"- <br /> 1123 W. Second Street, Grand Island, Nebraska 68801 <br /> 23. IMMEqATE CAUSE �ENTER ONIY ONE CAUSE PEA UNE FOR la6 Ibl.AND(cll �� Imerval between onset and oeav, <br /> PART <br /> ' �a, Cardio ulmonar failure unknown <br /> � DUE TO,OR AS A CONSEOUENCE Of � In�erval belween onsel and neam <br /> (b� ' <br /> DUE TO.OR AS A CONSEQUENCE OF� ' Imervai beiwaen onsei and dea�n <br /> i <br /> ��� i <br /> OTMER SIGNIFICANT CONDITIONS-CmOi�ions conlriMfirg io me tleath but no1 relatetl PART III IF FEMALE.WAS THERE A 24.AUTOPS� '25.WAS CASE REPERRED 70 MEDICAL <br /> PART PREGNANCV M THE PAS7 3 MONTHS7 EXAMINER OR CORONEF1' <br /> II 7� <br /> mus eular � .S tr� LL IAges 70-54� Yes No Ves No Yes � No � <br /> Na. 26b.DATE OF INJURV /MO..DaV y�l Z�.HOUR OF INJURV 260.DESCRIBE HOW INJURV OCCURRED <br /> � Accident � UnGB�ermineA M <br /> � Swcitle � Pentlmq 26e.INJURV AT WORK 261.PLACE QF INJURV-A1 home.larm,street.lactory 26g.LOCATION STREET OR R f.D.NO. CITV OR TOWN STATE <br /> ❑ ❑ ❑ oXice bunairg.etc lSpeciNl <br /> Homlcitle Investgaaon Ye5 No <br /> 27a.DATE OF DEATH (MO.Day YrJ 28a.DATE SIGNED /MO_Day Yr.l 28b TiME OF DEA7H f oun d a t <br /> a� t�w . <br /> �� �/ -�G � . a M <br /> �� 27b.DATE SIGNED /MO.Day.Yc) 27c.TIME OF DEATH �i F 28c.PRONOUNCED DEAD / o_Day,Yi.) 28tl.PRONOUNCED DEAD /HOUn <br /> a� <br /> E�� M gi��A ril �� � ' M <br /> 27d.To tlie bast d my knowleUge.deaM occurretl at Ne time.Uale antl place an0 Aue lo the ��u 28e.On the basis of examinatio�arW,o inv � � my ion tlealh occurr al <br /> eause�sl stated. - me time,date aM place 'tlue cau <br /> Si naWre an0 Tille �51 nalure and Tlne ► � - <br /> 2i.dD TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br /> 30.b WASCONSENTGf7ANTED� <br /> � YES � NO � UNKNOWN � VES � NO � VES � NO <br /> �� <br /> 31.NAME AND ADDRESS OP CERTIFIEA(PHVSICIAN,CORONEfiS PHVSICIAN OR COUNTV ATTORNEYI /Type p Prinry <br /> 7ta. GISTRAR 32b. ATE FILED 8V REGISTRAR /MO..Day.YcJ <br /> . <br /> APR 2 71999 <br />