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<br /> WHEN TH/S COPY CARR/ES THE RA/SED.SEAL Of THE NEBRASKA STATE DE�4#TMF.IK'l-fl�NfALTH,
<br /> ?CERT/f/ES THE BELOW TO BE A TRUE COPY OF AN OR/Q/NAL RECORQ_�1lI flLE W/TH Tf��ATE
<br /> DEPARTMENT OFHEALTH,BUREAU Of V/7AL STAT/ST/CS, WH/CH/S Ffi1E-,EEO,�fiDE�S/7'���R
<br /> • V?AL RECOROS. - _- __Y�"'�--"
<br /> 1
<br /> DATE OP/SSUANCE - ��
<br /> SEP 2 0 1995 9 9 10 915 9 .� =s�� � co�
<br /> A3S/STAN��TATE-�tEGlSF�4R
<br /> _, L/NCOLN,NEBRASKA NEBRASKA-aEPARTINENT_OFtIEJfLTH
<br /> STATE OF NEBRASKA-DEPARTMENT OF MEALTM
<br /> BUREAU OF VITAL STATISTICS
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT-NAME FIRS7 MNDDIE UST 2.SEX 3.DATE Of pEqTM /Mwnm.Ory.Yq.J
<br /> Jack Lee Denman Male September 7, 1995
<br /> 4.CITV ANO STATE OF&RTH lMnof n USA..name cprMy/ Sa.AGE-La�t&rtlitlay UNDER 1 VEAF UNDER�DAV 6.DATE OF BIRTH /MpM1,pay year)
<br /> Grand Island, Nebraska "`�� 71 5D M°5 ��S x_"°"� �"S November 28, 1923
<br /> 7.SOCIAL$ECUHTIV NUMBER 9a.PUCE OF DEATH
<br /> 506-20�5072 �R!� � �^p�M OTMER � Nur,urgMOme
<br /> 9b.FACIUTV•Neme //ndu,shhdan,9nrsneefaMnumWrl � EROu�ryeM � Res�Oente
<br /> St. Francis Medical Center ❑ �A ❑ o��s�,N,
<br /> x cm.rown oa�oc�rior,oF o�rN ea ws�oe crrr uMrrs ee courm oa o�rH
<br /> Grand Island Y.� � �„ � Hall
<br /> 9L REStDENCE-STATE 9E CWNTV 9c.CITV.TONM OR LOCATION 9tl $TREET AND NUMBER :ht.Yd�uigZp CodeJ 9e INSIDE CfTV UMITS
<br /> Nebraska Hall Grand Is.land 3548 Hillside 68803 �.��{] ��
<br /> �0.HACE-Is.p..WhiM.&ack.Amsncen Man, t 1.ANCESTRV le.g..Its6n.Mezican.Gsmian.e�cl t 2.�MARRIED �YVIDOWED 73 NA►�OF SPOUSE In wne.prvy meiden namsl
<br /> e1c.11Spscdyl (SWCAYI NEVER pNORCED
<br /> White Gladys Bohner
<br /> 14i.USUALOCCUPATqN /Gn+ekiipd•orAOa�ealu�ingm�f 1rb KINDOFBUSINESSINWSTRV � 15.EDUCATqN I
<br /> ��h«�N�a+as�«�w�nw�
<br /> d���.�/��/ EbmerrtaryaSsconCary10��21 CdNgel�.ea5•i
<br /> Farming Agriculture 12
<br /> 18.FATHER•NAME FFST MIDpIE UST 17 MpTHER FIRST MIDDIE MAIDEN SURNAME
<br /> Loyal Hathaway Denman Mayme Edna Franz
<br /> 18.WAS DECEASED EVEf11N U.S.ARMED FORCES? 19a.WFORMANT-NAAAE
<br /> (�'�nl,p{�I IM w wr W d aervkwl
<br /> YLl WWI�i. .l�/45 -10/29/46 Gladys Denman
<br /> 1BD.INFORAMNT MAILNIG AOOiiESS ISTREET OR 0.F.D.NO.,CT'OR T01NN.STATE.ZIP�
<br /> 3548 Hillside, Grand Island, Nebraska 68803
<br /> Z0.E R-SIGNAT 8 ENSENO. �j�� 21a.A�TFIODOFpSPOS�TqN 21C.DATE 21c.CELIE7ERYORCREMATORY�NAME
<br /> ` �X e�,�w ❑�� Se t. 11 1995 Westlawn Memorial Park
<br /> 22i.FUNEqAI -NMIE � 21d.CEMETERY OR CREMATORV LOCqTION CITV pR TOWN STATE
<br /> Livingston-Sondermann F.H. ❑°r"""°" ❑°onao°" Grand Island, Nebraska
<br /> ?2b.FUNERAL FIOYE ADORESS ISTREET ON 0.F.D.NO..CfTV OR TOWN.STATE,ZIP�
<br /> 505 West Koenig, Grand Island, Nebraska 68801
<br /> 23. MMIEDIATE CAUSE (ENTER qJIY ONE CAUSE PER LINE FOR Ia1.Ib�.AND(c11 i ktervai oenvsen awi ana aea
<br /> v�ar G''(� ���+ � .Y M�►"�cQ,��
<br /> DU TO.OR AS A CONSEWENCE OF� i Ir�rvai between oruei ara aeam
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<br /> DUE T0.Ofi AS A CplSEOUENCE OF� i Imerval be�ween onset aM tleam
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<br /> OTHEF SIGNIFICANT CONDITIONS-ConAilans co��CuEng b the tleath dA nd related PAR7111 IF FEMALE.WAS THERE A 2�AUTOP$V 25 WAS CASE REFEFRED TO MEDICAL
<br /> PART PREGNANCV IN TNE PAST 3 MqJTHS�
<br /> x EXAMWERORCORONE %
<br /> II
<br /> IM��0-51) Ves No Ves No Yes No
<br /> 26a Z6b.DATE OF IWURV /MO..Oay.n.J 26c HOUq OF INJURV Z60.DESCRIBE HOW INJURY OCCURRED
<br /> � ActMenl � UrWalermined ,
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<br /> � $u�citle � Pendrg ZBe.MUUfiV AT WORK 261.PUe E OF��Y%�1t __ ,fym.slreel.facbry 26g.LOCATpN STREET OR RF.D.NO. GTV OR TOWN STATE
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<br /> 27a.DATE DEATM�Ab.Day.n.) 288 DATE SIGNED /Mo_Dey.qJ 280 TIME OF DEA7H
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<br /> �� 27b DATE NED Ma.Day.Yrl 27c TIM�jOF 6� 2& PROf�IpUryCED DEAD /Ab.Diy.Y.� 28E.PRpNOUNCED DEAD /Fwv�ai
<br /> �� y' 13/9 � �l ` bO� M �aio M
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<br /> 27A To tlie DsN d my k Oge. eetli oCCUrretl at��antl dete Cue�o MB ��� 2Be.On me bavs d esamxmaon and a ipn,in
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<br /> 2D.pD T USE CONTiiIBUTE TO THE DEATH'+ 308 MAS OR('AN OR TISSU DONATpN BEEN CONSIDERED� 30.D W�S CONSENT GRANTED�
<br /> YES � NO � UNKIqWN 1c VES � NO � VES NO
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<br /> 31 NDADqiES50FC HYSICIAN,CORONER�SPHYSICYINORCWNTYATTORNEYI /TrysnPrnN/
<br /> �Q� , 3016 W. Faidley Ave. , Grand Island, NE 68803
<br /> 3b.REOISTRAR 32D.DATEFIID SEP 1 �1�9�
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