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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU)NAMMMMES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECONW-097-XE W17W
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICk SO&MI, - - j S___
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200403614 A�At_ANLEV COOPER,
<br />ASSISTANT STATE RebarnAR
<br />&POLL, U99KA HEALTH AND HUMAN SCR Q0*ftTEf4-_7_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A14PSUFIPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DEAF 0 T,,
<br />DE
<br />I LIF(ELk-NI -NAVE 3 0A TE OF
<br />Donald Stewart Roush_ 'Male �May 28, 2000
<br />1-4 _-f_"_ANR STmFj_F ",t 11 11 T� A 5,, AGE LK,18,11,0., I jNDE-1 UNDER DAY 16 DATE 01 PIRT- Woth i,
<br />[_5h M(13 DAYS HOURS MhNS 1 1
<br />Lincoln, Nebraska 69 J_January 4, 1931
<br />7p U SECURTIY - uLACE F DEATH
<br />HOSPITAL OTHER
<br />■ 507 -30 -9647 ER OIpat,em Re,he,),,
<br />6h FACILITY 'Name W . .. .. . ....... �
<br />2915 S. Locust St. DOA 0,, s.,,
<br />rr-a - H 0 1
<br />P JO INSIDE CITY LIMPS 8C f�OUNTI ,)F DEATH
<br />8, CITY T AT T) N
<br />le, [X] No ❑ Hall
<br />_Gr,an d jid.
<br />�Qa RESIDENCE STATE T 91, (.0L)NTY 9c CI T TOWN OR LOCATION —9d STREUANDNU MRI]7R ng %C""; �IVJS
<br />8801
<br />Nebraska Hall rand Island 112915 S. Locust St. Y"
<br />MARRIED --- *IDOINED
<br />16 RACE eg Wrr.,, Ba,,� I I ANCE Itahad Me, can German el, 13 NAME OF SPOUSE 1' , I,,
<br />I et,: I Su,(4, fy, ❑ NEVER :),VOH,EO IMarlene L e s c h i n s k y ❑ white American Ej MARRIED
<br />11, EDUCATION S::fecl��nl�n,qneatg,ac holeted
<br />14a USUALOCCUPAT,-)r, 11r KIND OF BUSINESS INDUSTRY ----
<br />L c CITY TOWN OR IOCA ' ION
<br />rand Island a d
<br />ha_ i. a M.
<br />"a
<br />of rk q 141 Fle'u,"ta'y or Second—
<br />tree service 1 A r b o r i s t
<br />R, I F, SURNAME
<br />6 FATHER NAME FIRST MIDDLE LAST 11, MOTHER FIRST MIDDLE MAIDEN
<br />David Roush_ Ruth Horr
<br />IS A"" 1' CPC S 'q' 111IRMANT NAIVE
<br />Yes . 4", _ 1
<br />111, a , 1,/,,55-1/30/6j
<br />y es ]Korea - 1/13/48-1/30/x,2___ Marlene Roush
<br />190 INFORMANT MAILING ADDRESS .STREET ORRF D NO CITY OR IOIAIN STATE Zip) 29 15 S. Locust S t.
<br />Grand Island, NE. 68801
<br />-ALMER SIGN AiUAE&UC NO 7210 DATE
<br />21c CEMETERY ORCRF%IA' R NAME
<br />01 �a y 30. 2000 'Anatomical Board NE
<br />2 _R iT , IP TOWN STA-
<br />A N1 CEMETERY CREMATORY LOCATION
<br />-07� FUNERAL HOME' N
<br />All Faiths Funeral Home Omaha, Nebraska
<br />220 FUNERAL HOME ADDRESS (STREET OR R F D NO CITY OR TOWN STATE ZIPI
<br />2929 S. Locust St. Grand Island, NE. 68801
<br />—_ —
<br />r23 -ER LINE FOR ai th AND IT, Ile" t'dTen )r 'T I
<br />'23 IMMEDIATE _Al. SE ENTER omL ONE
<br />PAR? I , a, Cardiac arrest unknown
<br />7 DU E TO OR AS A CONSEQUENCE OF
<br />,p
<br />')IIE TO OP AS A CONSFF)tWfZCOF
<br />Yl!f L�T.lq 1. r" lot not "i �11�
<br />T HE ' N ;1 'NI AN- CCNLIITT,�NS Conn nm"T Pi I- FEMALE !,aERE A 1a AIJTOPSl
<br />I f`AH ANC', HE
<br />A,;,,, '') 14,
<br />-2-b-a - 26-h 6AT-F-164 IN U-1 -"AO 0,W _)_F 1,1 H' RHED
<br />26e INJURY AT V)ORK df,, OLA�E,OFtN - R`r A, 'I t. 'Y 26q -'C AT iI BEET ORRF NO
<br />S A,
<br />H11 ,1 Yes U No ❑
<br />TF OF DEATH Mo Day Yrt
<br />DAT11IGNIT) 111, 11, 1,' 1 IF DEATI�
<br />T
<br />6 -
<br />0 - 45
<br />11 27, TIME OF DEATH
<br />�D 2 8,- PPOW)UNCED F)FAE 1Mo Day Y( ?Hl -RC II "'R
<br />E
<br />e
<br />M 2000 am
<br />281, a of laom, and .1 ole,Tgat 'D "o- 1-1 VI
<br />:1) 27; sr of .,)y Heath at int, Id !at, 3-1 anc 1 rh, Hate and place and due to the Cc— I sIat�d
<br />01� tales, t " � and T,de,
<br />1— -1 I'll d T,flej 10
<br />29 DID I OBACCO j ;F ON T RIBIJ TF TO THE DEATH" TTO-THAS, DRGAN OR TISSUE DONATION BEEN CONSIDERED' 101 WASCONSENTGRANTFD'
<br />N(, JNKNOWN I IS N. ❑ 'rS
<br />_31 NAME AND ADDRESS OF CERTIFIER PHYSiCIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( Type or Pf,
<br />(Sgt D Vitera, GIPD, 131 Locust, Grand Island, NE 68801
<br />32a REGISTRAR T32b DATE FILED BY REGISTRAR IMO Day
<br />JUN 9 2000
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU)NAMMMMES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECONW-097-XE W17W
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICk SO&MI, - - j S___
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200403614 A�At_ANLEV COOPER,
<br />ASSISTANT STATE RebarnAR
<br />&POLL, U99KA HEALTH AND HUMAN SCR Q0*ftTEf4-_7_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A14PSUFIPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DEAF 0 T,,
<br />DE
<br />I LIF(ELk-NI -NAVE 3 0A TE OF
<br />Donald Stewart Roush_ 'Male �May 28, 2000
<br />1-4 _-f_"_ANR STmFj_F ",t 11 11 T� A 5,, AGE LK,18,11,0., I jNDE-1 UNDER DAY 16 DATE 01 PIRT- Woth i,
<br />[_5h M(13 DAYS HOURS MhNS 1 1
<br />Lincoln, Nebraska 69 J_January 4, 1931
<br />7p U SECURTIY - uLACE F DEATH
<br />HOSPITAL OTHER
<br />■ 507 -30 -9647 ER OIpat,em Re,he,),,
<br />6h FACILITY 'Name W . .. .. . ....... �
<br />2915 S. Locust St. DOA 0,, s.,,
<br />rr-a - H 0 1
<br />P JO INSIDE CITY LIMPS 8C f�OUNTI ,)F DEATH
<br />8, CITY T AT T) N
<br />le, [X] No ❑ Hall
<br />_Gr,an d jid.
<br />�Qa RESIDENCE STATE T 91, (.0L)NTY 9c CI T TOWN OR LOCATION —9d STREUANDNU MRI]7R ng %C""; �IVJS
<br />8801
<br />Nebraska Hall rand Island 112915 S. Locust St. Y"
<br />MARRIED --- *IDOINED
<br />16 RACE eg Wrr.,, Ba,,� I I ANCE Itahad Me, can German el, 13 NAME OF SPOUSE 1' , I,,
<br />I et,: I Su,(4, fy, ❑ NEVER :),VOH,EO IMarlene L e s c h i n s k y ❑ white American Ej MARRIED
<br />11, EDUCATION S::fecl��nl�n,qneatg,ac holeted
<br />14a USUALOCCUPAT,-)r, 11r KIND OF BUSINESS INDUSTRY ----
<br />L c CITY TOWN OR IOCA ' ION
<br />rand Island a d
<br />ha_ i. a M.
<br />"a
<br />of rk q 141 Fle'u,"ta'y or Second—
<br />tree service 1 A r b o r i s t
<br />R, I F, SURNAME
<br />6 FATHER NAME FIRST MIDDLE LAST 11, MOTHER FIRST MIDDLE MAIDEN
<br />David Roush_ Ruth Horr
<br />IS A"" 1' CPC S 'q' 111IRMANT NAIVE
<br />Yes . 4", _ 1
<br />111, a , 1,/,,55-1/30/6j
<br />y es ]Korea - 1/13/48-1/30/x,2___ Marlene Roush
<br />190 INFORMANT MAILING ADDRESS .STREET ORRF D NO CITY OR IOIAIN STATE Zip) 29 15 S. Locust S t.
<br />Grand Island, NE. 68801
<br />-ALMER SIGN AiUAE&UC NO 7210 DATE
<br />21c CEMETERY ORCRF%IA' R NAME
<br />01 �a y 30. 2000 'Anatomical Board NE
<br />2 _R iT , IP TOWN STA-
<br />A N1 CEMETERY CREMATORY LOCATION
<br />-07� FUNERAL HOME' N
<br />All Faiths Funeral Home Omaha, Nebraska
<br />220 FUNERAL HOME ADDRESS (STREET OR R F D NO CITY OR TOWN STATE ZIPI
<br />2929 S. Locust St. Grand Island, NE. 68801
<br />—_ —
<br />r23 -ER LINE FOR ai th AND IT, Ile" t'dTen )r 'T I
<br />'23 IMMEDIATE _Al. SE ENTER omL ONE
<br />PAR? I , a, Cardiac arrest unknown
<br />7 DU E TO OR AS A CONSEQUENCE OF
<br />,p
<br />')IIE TO OP AS A CONSFF)tWfZCOF
<br />Yl!f L�T.lq 1. r" lot not "i �11�
<br />T HE ' N ;1 'NI AN- CCNLIITT,�NS Conn nm"T Pi I- FEMALE !,aERE A 1a AIJTOPSl
<br />I f`AH ANC', HE
<br />A,;,,, '') 14,
<br />-2-b-a - 26-h 6AT-F-164 IN U-1 -"AO 0,W _)_F 1,1 H' RHED
<br />26e INJURY AT V)ORK df,, OLA�E,OFtN - R`r A, 'I t. 'Y 26q -'C AT iI BEET ORRF NO
<br />S A,
<br />H11 ,1 Yes U No ❑
<br />TF OF DEATH Mo Day Yrt
<br />DAT11IGNIT) 111, 11, 1,' 1 IF DEATI�
<br />T
<br />6 -
<br />0 - 45
<br />11 27, TIME OF DEATH
<br />�D 2 8,- PPOW)UNCED F)FAE 1Mo Day Y( ?Hl -RC II "'R
<br />E
<br />e
<br />M 2000 am
<br />281, a of laom, and .1 ole,Tgat 'D "o- 1-1 VI
<br />:1) 27; sr of .,)y Heath at int, Id !at, 3-1 anc 1 rh, Hate and place and due to the Cc— I sIat�d
<br />01� tales, t " � and T,de,
<br />1— -1 I'll d T,flej 10
<br />29 DID I OBACCO j ;F ON T RIBIJ TF TO THE DEATH" TTO-THAS, DRGAN OR TISSUE DONATION BEEN CONSIDERED' 101 WASCONSENTGRANTFD'
<br />N(, JNKNOWN I IS N. ❑ 'rS
<br />_31 NAME AND ADDRESS OF CERTIFIER PHYSiCIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( Type or Pf,
<br />(Sgt D Vitera, GIPD, 131 Locust, Grand Island, NE 68801
<br />32a REGISTRAR T32b DATE FILED BY REGISTRAR IMO Day
<br />JUN 9 2000
<br />
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