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CO � <br /> � � N <br /> � ` ° (�'�w = m � � <br /> � rn �i, -p � � p � <br /> � � � <br /> �' ''' � t' D "� � <br /> � ,�-. �, F-+ � CD � <br /> D <br /> . �� C.� ..�.... � r��-F <br /> .� N W Z <br /> � O <br /> g9 �07803 <br /> WHEN TFUS COPYCARR�S lif RA13ED SEAL OF THE NEBRA31(A HEALTH AND HlfMAl��EA4�GES <br /> SYSTEII�IT CERT�ES THIE BELOW TO BE A TRUE COPYOF THE OR/OINAL R��f„�/ <br /> THE NEBRASKA HEALTH AND HUMAN 3ERNICES 3YSTEM,VITAL STATIST���T�(� <br /> THE LEOAL DEPOSITORY FOR VITAL RECORD� �i - -_- _- =:. <br /> DATEOF/SSUANCE _ �Y���'� � <br /> �����_���1��- �' _ <br /> JUL 1 51998 °�= <br /> ass�ss��sr����� <br /> L/NCOLN,NEBRASKA HEALTHAND H111�AN 3E�$;3yg�'Ejl�� <br /> sr�rE oF xsax.�sx�-n�,�xn�arr oF[�.ni�xn xutiurr sExvf�s�3Pria7��p.�ue�33Rr <br /> vrr�u.sr�nsrics '-_ -: - -- - <br /> CERTIFICATE OF DEATH --=_ <br /> 1 DECEDENT-NAME FIFST MIDOLE UST 2.SE% 3.DATE OF DEATH /MnnM.Day.Ysar) <br /> Jimmie � C. Joh son Male Jul 3 1998 <br />�.pTV AND STATE OF BIRTM /Nno(ir US.A..MnMCdnhyl Se.AGE-UM&NWay UNDER 1 VEAR UNOER 1 DAV 6.DATE OF BIRTM /MOrM1.Day.YeJr� <br /> (��s.l Sb.MOS. I DAVS Sc.HOURS- MINS. <br /> Hall Count , Nebraska 77 June 17 1921 <br /> 7.SOCIAL SECURTIV NUMBER Ba.PLACE OF DEATH � <br /> 506 20 4679 HOSPITAL: � lnpafieM OTHER � NursingHpme <br /> Bb.FACIIITV-Name /Nnol�nsfilufion.pivBShselandnunWN/ --��- � EROutpetieM � qesMence <br /> VA Greater Neb Health Care System � o�A � o,,,,,�s�,�,ty, m � � <br /> c m <br />&.CITV.TOWN OR LOCA710N OF DEATH Bd INSIOE C�n'L�MITS Be.COUNTV OF DEATH Q n �p <br /> Grand Island `� " <br /> vs5 [� uo ❑ Hall `D '^ �' <br /> n .- m <br /> 9a RESIDENCE-STATE 9b COUNTV � 9c.CITV.TOWN OR LOCATION� 9d.STPEET AND NUMBEA llrrcluCiipZpCodeJ ge.INSIDE CITV LIMITS � � � <br /> Nebraska Hall Grand Island 514 W 7th 68801 "°'� "�❑ ° � � <br /> M <br /> 10 RACE-(e.g.,Whi1e:Black.Amencan Indian. 1 t.ANCESTRV le.q..llalian.Medean.Gxman,stc� . 12.�MARRIED ❑WIDpWEO 13.NAME OF SPpUSE ld wAe.grve maiden name) � � r <br /> 7 Z r� <br /> e�c.l�Soeafyl ��'M NEVEF DiVORCED <br /> White Greek Dorothy L Switzer � � rn <br /> 1<a.USUAL OCCUPATION /G�e kiMd wwk doneCwiny mnal 1 Cb KIND OF BUSINESS INDUSTRV 15.EDUCATION �Speclly oNy hphs3l qrWS tomplNetl� 01 (� r,� <br /> Ol wWkrng li/B.evBn iliehrp� ElerrbMary Or$eeqlEBry 10-121 It-�a SH a 9 v <br /> Barber Hair cutting � 12 `'°"� � 3 <br /> 16.FATHEF-NAME fIRST MIDDLE LAST 17.MOTMER FIRST � MIGUL: MAIOEN SURNAME � � � <br /> '^� s <br /> dec. Christ Johnson dec. Nellie Maude _ Nitchell � � ,� <br /> t8.wAS DECEASED EVER iN U.S.ARMED FORCES? 19a.INFOqMANT-NAME � � O <br /> M (A (/� <br /> I�es�o.or unk.� 1��yes.qrve war anE Oaies d aervieeaj ' � � <br /> Yes WWII 11-5-42 10-11-45 Dor� h �ohnson � �� x <br /> 19D INFORMANT MAILING AODRESS ISTqEET OR R.F.D.NO..CITV OR TQV/N_STATE.ZIPI � � ^ <br /> '1 a v <br /> 514 W 7th Gr nd Isl d N 1 .- � <br />?0 MBALMER-SI NATU E 8 UCENS 21a.METHOpOF qSPO51Ti0N 2t0.DATE 21c.CEMETERV OR CREMATpRV-NAME n a ; <br /> � M F+� <br /> • /S �X ���a� �Removal Jul 8, 1998 Grand Island Cit Cem. „ ^ m <br />>2a FUNERAL OME-NAME 21E CEMETERV OR CAEMATOA�LOCATION CITV CR TONM STATE O O <br /> A fel-Butler-Geddes F.H. �G"""�' �°oni�' Grand Island, Nebraska <br /> � O � <br />>2p FUNERAL H01:1E AODRESS ISTREET OR R.F.D.NO..CITV pR TOWN.STATE.ZIP� � � <br /> P 17 fD <br /> 1123 W. Second Street, Grand Island, Nebraska 68801 n �;,� <br />?3. IMMEDIATE CAUSE � �ENTER ONLV ONE CAUSE PER LINE FOR�a1.IDI.ANO(c�j � Imerval Oelwe9n onsel antl tlealh m � <br /> PAfiT � O µ a <br /> � Congestive heart failure - Acute � 2 Weeks �+, � � <br /> fa1 � <br /> DUE TO,OR AS A CONSEOUENCE OF: � IMerva1 Delwsen onsel anC Aeatn h � a <br /> � n o- <br /> i„ Cardiomegaly � 3 Years o ""y <br /> DUE TO.OR AS A CONSEOUENCE OF' � ���,e��������a�� � a � � <br /> � • w n <br /> i <br /> 1�1 � a`� <br /> OTHER SIGNIFICANT CONDITIONS-Contlitpns coMriWNny b M8 death bu1 rql relatetl PART III IF FEMALE.WAS THERE A 2a.AUTOPS� 25.WAS CASE REPERRED TO MEDICAL <br /> PART COPD, Uremia cirrhosis PREGNANCYINTHEPA5T3MONTHS? EXAMINERORCORONER� ~ � <br /> m <br /> •(Ages�0-541 Ves No Ves No Ves Np "' <br /> m y <br />?6a. Z6b.DATE OF INJURV /MO..Day.Yi./ 26c.MpUR pF INJURY 260.OESCRIBE HOW INJUHY OCGURRED a , <br /> G� N <br />] Acatlern � Unaeierm�neE • N <br /> M � <br />� SwaOe � Perb�ng 26e INJURY AT WpRK ,261.�P�qe�p���U�qy%g��rne�,�arm,stree�.tactory 26g.LOCATION STREET OH R.f.O.NO. CI7v OR TOWN STATE � r„ <br />� � � yP"� � � <br /> Homicbe invesugauo� Ves No ,� <br /> m C <br /> 27a DA7E OF DEA7H /MO_DaY y��) � 28a.DATE SIGNED /Ab..Day vrl 28D.TIME OF DEATM t0 7 <br /> � O <br />�a July 3, 1998 a=w M _ , <br />�� 27E DATE SIGNE� /MO.Day.Vr/ 27t.TIME OF DEATM `�i'� 2Bc.PRpNOUNCED OEAD lMO.Q�y,Yc/ 2BC.PRONOUNCED OEAD /fbwl <br /> x�� July 7, 1998 1 :15 pM ���� <br /> g M <br />-a 27tl.T d m�wletlg. otturr tM U e an0 place antl Oue b IM 28e.On NB Wlis of aRaminatan aM'a inwslgali0n,in my Opinion Osalh oCCUrraE at <br /> sl 5 1 Me time.OBb aM __ <br /> � /'' �f�are �.� paca arW due a u�s esuse�s4 s�wd. <br /> ( and Trtlel► - "� ��- '�""G S�nalu�e antl TiMe � <br /> 9.DID TOBACCO USE CON7RIBUTE TO THE DEATM4 3p.a HAS OHGAN OR TISSUE DONATION BEEN CONSIDERED? 30.E WAS CONSENT GRANTED? <br /> � VES � NO ❑X UNKNOWN � VES � NO � VES ❑X NO <br /> t.NAME AND AODRESS OP CERTIfIER IPHVSICIAN,CORONER'S PMVSICIAN OR CWNN ATTOFNEVI lTypsaPobp . � <br /> Russell E. Cramm, M.D. VAGNHCS 201 North Broadwell, Grand Island, Nebraska 68803 <br /> 2a.REGISTRAR <br /> • 32b.DATE FIIED BV REGIi i i i � �y �L�� .. <br />