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<br />R
<br />N
<br />WHEN THIS COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -OWRLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT 1S77C#Q1itCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />ANLEYS. �OOR�f
<br />3/19/2004 200403115 ASSISTANT S�10 _ §Ll i!fW -
<br />LINCOLN, NEBRASKA HEALTH AND I UMAN SERVICES SYSTtAt
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIIC_ESiW�T�y4NCEAND SP4_T
<br />VITAL STATISTICS - _ -
<br />rP..RTTFTC A'TR OF nFATH _ n A
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<br />O
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<br />CD
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<br />G
<br />n *Qnai
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />M
<br />A
<br />n
<br />`March 8, 2004
<br />4. CITY AND STATE OF BIRTH (It not ar U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Moratr. Day. Year)
<br />MOS. I DAYS
<br />So. HOURS' MINE.
<br />Princeton, Minnesota
<br />'Y-' 82 5b.
<br />January 24, 1922
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL O Inpatient OTHER: ❑ Nursing Home
<br />476-10-9516
<br />n
<br />z
<br />• St- Francis Medical Cenfp-r
<br />❑ DOA ❑ Other (Specify
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Z
<br />Hall
<br />ga. RESIDENCE -STATE
<br />COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncludkg Zip Code)
<br />Nebraska
<br />19b.
<br />Hall
<br />Grand Island
<br />1 01 2 N. Sheridan Av
<br />o No ❑
<br />10. RACE - (e.g, While. Black. American man.
<br />11. ANCESTRY (e.g_ Italian. Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /lt wde. give maiden name)
<br />M
<br />N
<br />y
<br />Viola Fu l 1 e t on
<br />W`�i�,e
<br />t
<br />e dish
<br />MARRIED
<br />"< O
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -12) College 0 -4 or 5 -1
<br />c/ working life, even d refired"
<br />Dealer -Owner
<br />Implement
<br />O T
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />JITMOTHER
<br />Alfred H. Johnson
<br />Ruth A. Nordstrom
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? -•
<br />1Be. INFORMANT -NAME
<br />(Yes. no. or unk.) (8 yes. give war and dates of services)
<br />Yes m WWII 1 -1
<br />Vi61a Johnson
<br />19b. INFORMANT AILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP)
<br />10n N1 Sh idan Av Grand Island NE 68803
<br />20. E ER - SIGNATURE 8 CENSE NO. - -
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />a
<br />�
<br />3 -12 -2004
<br />� rn
<br />22a. F AL HOME -NAM
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑°ens° ❑Donatac
<br />Fullerton, NE
<br />rn
<br />A-
<br />O
<br />A co
<br />210 Irving, P.O. Box 332, Fullerton, NE 68638
<br />23. IMM ATE CAUSE `ti (ENTER ONLY ONE CAUSE PER LINE FOR lab (b). AND (q) I Interval between onset and death
<br />PART
<br />TO, OR AS A CONSEQUENCE OP I DUFnteAral between onset and death
<br />I
<br />I
<br />I
<br />M
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />r
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II�
<br />1
<br />(Ages 10 -54) Yes No
<br />r D
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /Mo.. Day. Yr ;
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW IN,iJRV OCCURRED
<br />Lo
<br />M
<br />to
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. a ACbE Obi INJURY �At fir, farm. sheet factory
<br />SPac
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />~
<br />D
<br />27a. DATE OF DEATH /MO.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. A)
<br />28b. TIME OF DEATH
<br />March 8,2004
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<br />271b. DATE SIGNED /Ma. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />M. PRONOUNCED DEAD (Houil
<br />s G }
<br />March9,200
<br />6:20pm M
<br />�_�
<br />s
<br />M
<br />27d. To the best of my knowledge) death curr at the Bme,Aat8 place and due to the
<br />28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />$
<br />causelsl stated. , %fV
<br />O
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<br />O
<br />O
<br />O
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<br />CD
<br />`.n z
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<br />n *Qnai
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3.DATE OF DEATH .YMonth. Day. Year/
<br />Robert Alfred Johnson
<br />Male
<br />`March 8, 2004
<br />4. CITY AND STATE OF BIRTH (It not ar U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Moratr. Day. Year)
<br />MOS. I DAYS
<br />So. HOURS' MINE.
<br />Princeton, Minnesota
<br />'Y-' 82 5b.
<br />January 24, 1922
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL O Inpatient OTHER: ❑ Nursing Home
<br />476-10-9516
<br />❑ ER Outpatient ❑ Residence
<br />fib. FACILITY -Name /I/ not inshfutim give sheet and number)
<br />• St- Francis Medical Cenfp-r
<br />❑ DOA ❑ Other (Specify
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />ga. RESIDENCE -STATE
<br />COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncludkg Zip Code)
<br />T9e. IDE CITY LIMITS
<br />Nebraska
<br />19b.
<br />Hall
<br />Grand Island
<br />1 01 2 N. Sheridan Av
<br />o No ❑
<br />10. RACE - (e.g, While. Black. American man.
<br />11. ANCESTRY (e.g_ Italian. Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /lt wde. give maiden name)
<br />etc.) IS ify),
<br />IS rNl
<br />Sw
<br />NEVER DIVORCED
<br />Viola Fu l 1 e t on
<br />W`�i�,e
<br />t
<br />e dish
<br />MARRIED
<br />14a- USUAL OCCUPATION /Give kmdof work a'one during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -12) College 0 -4 or 5 -1
<br />c/ working life, even d refired"
<br />Dealer -Owner
<br />Implement
<br />11th
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />JITMOTHER
<br />Alfred H. Johnson
<br />Ruth A. Nordstrom
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? -•
<br />1Be. INFORMANT -NAME
<br />(Yes. no. or unk.) (8 yes. give war and dates of services)
<br />Yes m WWII 1 -1
<br />Vi61a Johnson
<br />19b. INFORMANT AILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP)
<br />10n N1 Sh idan Av Grand Island NE 68803
<br />20. E ER - SIGNATURE 8 CENSE NO. - -
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />I '�.
<br />❑x Buda) ❑Removal
<br />3 -12 -2004
<br />Fullerton Cemetery
<br />22a. F AL HOME -NAM
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑°ens° ❑Donatac
<br />Fullerton, NE
<br />Palmer Funerali`Homes
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />210 Irving, P.O. Box 332, Fullerton, NE 68638
<br />23. IMM ATE CAUSE `ti (ENTER ONLY ONE CAUSE PER LINE FOR lab (b). AND (q) I Interval between onset and death
<br />PART
<br />TO, OR AS A CONSEQUENCE OP I DUFnteAral between onset and death
<br />I
<br />I
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF - I Irteval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II�
<br />1
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /Mo.. Day. Yr ;
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW IN,iJRV OCCURRED
<br />Accident � Undetermined
<br />M
<br />126d.
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. a ACbE Obi INJURY �At fir, farm. sheet factory
<br />SPac
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /MO.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. A)
<br />28b. TIME OF DEATH
<br />March 8,2004
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<br />M
<br />271b. DATE SIGNED /Ma. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />M. PRONOUNCED DEAD (Houil
<br />s G }
<br />March9,200
<br />6:20pm M
<br />�_�
<br />s
<br />M
<br />27d. To the best of my knowledge) death curr at the Bme,Aat8 place and due to the
<br />28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />$
<br />causelsl stated. , %fV
<br />c>
<br />the time, date and place and due to the cause(s) slated.
<br />H ^
<br />Ill. (Si nature and Title ► - / 1••/
<br />( nature and Title) ►
<br />29. DID TOBACCO USE 11 TRIG E THE EATH?
<br />V.'a AS ORGAN OR TISSUE DONATION BEE4,CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES N,. �7❑ UNKNOWN
<br />/
<br />❑ YES � NO
<br />❑ YES ❑ NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print)
<br />Grand Island,NE 68803
<br />Dr J
<br />322 REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /MO.. Day. Yr)
<br />MAR 18 2004
<br />NJ
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