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r97 ��r� �V �� � 1� <br /> STATE OF NEBRASKA.DFpAR�f�OF F�'.ALTH AND HUMAN SERVICES FiNANCE ANp SUPPORT <br /> � "`�"��`"'�� 286559 <br /> ' CERTIFICATE OF DEA'TH <br /> t DECEDENT�NAME FIRST MIDOIE UST i SEX � DATE Of DEATH rAbnrn Wr rwi <br /> David Kenneth Brison Male July 10, 1998 <br /> � CtTV AND$TATE Oi B�ATM /Nnof n 115.A.iyrrw cpe►p Sa AGE-W18xtlWay UNOER 1 VEAR UNpEq t DAV 6.DATE OF&FTM lMOrNi Dar Ywl <br /> Chelah� Washington r"� 58 � �s i wrs x Hou�.s MINS June 21� 1940 <br /> 7 SOCIAI$ECURTIV NUMBEA Ea PI,ACE OF OEATM <br /> ' S 38- �oSP�TU � Mp�l OTMER ❑ Nursrcg Mome <br /> BO FAC4iTY-Hams (Nnd msO�Nat y�abser an0 MwrNM �_— � ER�� � Reaiaence <br /> � Bergan Mercy Hospital ❑ oo� � oe,e„s�,H <br /> & CITV TOWN Ofi LOCATIpN Of pEATM etl IN$IpE CITy UMRS OC COUNTV OF DEATFI <br /> Omaha �.. �X �w � Douglas <br /> 9a.RESIDENCE-$TATE 9D CWN1Y 9C.qTY.TOWN OR LOCATpN yp.STREET AND NUMBER (mcry�v�ylrpCoW/ 9�INSIDE qT`/LIMITS <br /> Nebraska Douglas Omaha 12770 "A" Street 68144 �.. XQ �❑ <br /> �0 RACE�le g_Whne&xR�Kan htlun. t t.ANCESTRV ie.g..MaMan.M�■�can,G�rm�n,«c1 �2 �MARWED ❑NADpWED t3 NAME OF SPOUSE iN w�k.qve mrdsn�ums/ <br /> "`��s°°""�Whi te l��l NEVER pVORCED <br /> American p Carol Michalski <br /> 1 aa 'JSUAL OCCUPATION iGrve kuMd work dana durrg mosr ttp KIND OF BUSINESS INDUSTqy 15 EDUCATION �Spanly pNy nghes�yra0e cortpy�) <br /> d�.or►mgieM.swnArenredl ENmsrnary rvi0-�21 Cdbqeii.oa5-i <br /> Computer Systems Specialist Computer Systems Integrati n �`�°`"itla p <br /> 76 FATMEH-NAME FiiST AYOOLE UST t 7 MOTMER FINST MIDDLE MAIOEN$URNAME <br /> � Arthur Adalore Brison Bertha :rru�e <br /> t8 WAS DECFJ�C�D E'lE�:IN V.5 M'iME�=ORC;-E3? tya INFORIAANT-NAME <br /> IVas no.a uNC.I Ip yes yne H anC le5 d a�rv�w <br /> Yes 6�21r57 - �/20/63 Carol Brison <br /> 19D INfORMANT MAll1NG ADDRESS ISTREET OR R.F.D.NO..CRY OR TONM.STATE.ZIP) <br /> 12770 "A" Street Omaha, Nebraska 68144 <br /> MER-SIGNAT E 8 L�CENSE NO. ��� Zla.METrqDOF pSPOSIT10N 21D.OATE 21Q.fFIdE5Epv111,i�Er,�9fD¢y JJ�1Ea7 <br /> Y1CSl1dW71 P1elllVil 1 <br /> �a,,,., ��„ July 15, 1998 �ark Cemetery <br /> 22a F�/NEFAI FpME-NAME 2/0.CEMETERY OH CREMATORY LOCATION GTV OA TpNM STATE <br /> Apfel-Butler-Geddes Funeral Hom ❑�^ ❑�^�^ Grand Island, Nebraska <br /> 22E fUNERAL MOME ADDRESS � ISTREET Qq 0.F.D NO..CITY OR TOWN.STATE DP) <br /> 1123 West Second Grand Island, Nebr ska 688 1-5899 <br /> 23. MIMEdATE C fENTER ONLV pNE CA R UNE FOR iai.IDf. Icll ' NMrval Oe�ween on sm <br /> PART � <br /> � 1 1 <br /> lil ' <br /> I <br /> DUE 70. A CONSEWENCE OF T � i ai bnwesn or�ano aeam <br /> 1�I ' <br /> DUE TO. A CONSEpUENCE OF i I ai Def.een onse�aro aeam <br /> Ic1 � <br /> I <br /> P�T OTIER$IC>NIFICANT CONDITIONS�CO�MbMS contibtpnp b M O�ah Dut nd rNeNE PART Ip K FEMALE.WAS THERE A 2� AUTpPSV 25.WAS CASE REFERRED TO MEdCAL <br /> M �HEGNANCY W TNE PAST 3 MONTMS� p(AAIINER Oq CQiipNER� <br /> (Aqsc 10.51) V�i No Yes No Yes No <br /> � 28C DATE OF INJURY /MO..Oq!�1 26c FqIlR1�MyURY 26Q DESGRIBE iqW INJURV OCCUHRED <br /> ❑ AcnOSrt � UMSfsrm� i M <br /> ❑ SuiciOe � Pwidnq 2Ee.MIJURY AT WOAI( 291.PLACE QF MUU�/L1l __ .yrm.51ree�I�t,Ypry 28p.LOCATION STREET OR R.F.O.NO CITV pq TOWN STATE <br /> dFCf d1I10111Q SQ/CA)/ <br /> ❑ "�� M� ru� roo� <br /> 2A OATE OF D..ErATMy„{M�.,qyWy„� ,��. 2Ea DATE SIGNED (MO.D�y.n/ 2Bp TIME Of DEIITM <br /> � ES -_. . . •�����,��� -'--� -- . 3j�yg M <br /> �� 47C DAT �SIGNED,(Ab Qy�dy � ', �,�7c TJME pF pF�►TM a�0 2!c PRONWNCED DEAD lMo.Ory.Yr.l '2Btl.PRpNpUNCEG DEAD lHOUri <br /> . E�� ' � .. ��6'a �ip+�I � + � � �¢�� <br /> 270�To NYe�d my k.. � oteur 'yi0 pyce�nE tlw b 7M ��c� 7ds On 9ie Gsp d e:am�napon yW pr nws in m M <br /> N O �gaoon. Y ap��on oeatn occunW at <br /> ..eau3eli�u1W. � c> � M Ems.OYe m0 P��an0 Oue b IM tawMSl�W <br /> � a�a rms► M•D• �.nn va rs� <br /> 29.d0 iOBAOCp USE CONTPoBUT . + � i �3p�MA$ppGAN pp TI$$UE pq1ATI0N BEEH CON$IOEREO� 30.D WAS CONSENT GRANTED� <br /> �.VES ,.�❑ NO ��0 UNKNOWN i�T�. � VES �NO � VES �NO <br /> �1 NAME �A �rSS�. IER IPM'SICIAN. R�S .VSICNN OR COUNTV ATTORNEYI l7rpl O'Rnp <br /> ' 7710 Merc Road Suite 428 Omaha, rIe 68124 <br /> 32a.REG15 , . �r � " 320.DATE FILED 8Y REGt57qAR fAb.Oa Yr. <br /> ;. <br /> ` •'`� AUG 51�9� <br /> .4 ; <br /> This certifies' this document to be a true eopy ot an original recocd on file vith vital <br /> Statiatics, Oouqlas County Health Departa�ent, dnaha, NeDraska. Certitied copies must have <br /> a rai�ed seal in the area to the lett, Reproductions o! thia green certificate are not <br /> lcqal copies. <br /> Date is�ued: A�G • S 199$ Reqiscrar: <br />