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<br />as WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />K THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAEI WHI ; H /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _
<br />w� 3/19/2004 20040387 aNLErr_ -_ DER
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<br />.. �, LINCOLN, NEBRASKA HEALTH; *HUMAN SERVICESY#8A
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<br />CERTIFICATE OF DEA7TV_- '' `' 04 0
<br />03094
<br />1
<br />1. DECEDENT -NAME FIRST MIDDLE - LAST 2
<br />2.' SIX 3
<br />3. DATE OF DEATH /Monts., Day. Ysad
<br />Niles Austin Miller M
<br />Male M
<br />March 02 2004
<br />4. CITY AND STATE OF BIRTH Onot in U.S.A.. name couneyl S
<br />Sa. AGE - Last Birthday U
<br />UNDER 1 YEAR U
<br />UNDER I DAY 6
<br />6. DATE OF BIRTH (MoIW. Day. Yearl
<br />Sb. MOS. DAYS S
<br />Sc. HOURS' MINS.
<br />Blair, Nebraska 7
<br />rre.l S
<br />February 23 1931
<br />7. SOCIAL SECURTIY NUMBER B
<br />Be. PLACE OF DEATH
<br />508 -30 -8187 H
<br />rt
<br />8b. FACILITY -Name /A'not inshkraon, give scree /and ^umber)
<br />St. Francis Medical Center ❑
<br />8c. CITY. TOWN OR LOCATION OF DEATH - 8
<br />8d. INSIDE CITY LJMITS B
<br />Be. COUNTY OF DEATH
<br />Grand Island Y
<br />Yee ® Na ❑ H
<br />Hall
<br />9a. RE DENCE - STATE g
<br />go. COUNTY 9
<br />9c. CRY. TOWN OR LOCATION 9
<br />9d. STREET AND NUMBER IMcluding2FP Cads/ 9
<br />9e. INSIDE CITY LBMT$
<br />Nebraska H
<br />Hall G
<br />Grand Island 5
<br />518 W 8th St., 68801 Y
<br />Yes 12 ❑
<br />- 10. RACE - (e.g, White. Black. American 1=7T7, .
<br />. ANCESTRY (e.g.. Itelien..Mexwan. German, ;;;i;7_
<br />lcl 1
<br />12. ❑ MARRIED ® WIDOWED 1
<br />Na
<br />�g� (
<br />(SDecdY) N
<br />NEVER DIVORCED
<br />Z
<br />a/ wgki life. even i/rekredl Elements 2ry o Secondary 10 -121 C
<br />16. FATHER -NAME FIRST MIDDLE LAST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harold (NMI) Miller Gladys (NMI) Reynolds
<br />' 1
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<br />rn
<br />(Yes, no. or unk.) fit yes. give war and dates of servideal
<br />Yes Korean War 07/11/1953 G
<br />Geor ene K. Miller
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />518 W 8th St., Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE & LICENS NO. 21 a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME
<br />1254 �e,,,;a, ❑ Rene�al 03/06/2004 Grand Island City Cemetery
<br />2 9
<br />22a. FUNERAL �ne 2
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<br />3213 W North Front St Grand Island, NE, 68803
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib1. AND (c)f I Interval between onset and death
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<br />as WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />K THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAEI WHI ; H /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _
<br />w� 3/19/2004 20040387 aNLErr_ -_ DER
<br />Iry
<br />.. �, LINCOLN, NEBRASKA HEALTH; *HUMAN SERVICESY#8A
<br />w STATE OF NEBRASKA- DEPARTMEN f OF HEALTH AND HI)M�1?i uppoitT
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<br />VITAL STATISTICS
<br />CERTIFICATE OF DEA7TV_- '' `' 04 0
<br />03094
<br />1
<br />1. DECEDENT -NAME FIRST MIDDLE - LAST 2
<br />2.' SIX 3
<br />3. DATE OF DEATH /Monts., Day. Ysad
<br />Niles Austin Miller M
<br />Male M
<br />March 02 2004
<br />4. CITY AND STATE OF BIRTH Onot in U.S.A.. name couneyl S
<br />Sa. AGE - Last Birthday U
<br />UNDER 1 YEAR U
<br />UNDER I DAY 6
<br />6. DATE OF BIRTH (MoIW. Day. Yearl
<br />Sb. MOS. DAYS S
<br />Sc. HOURS' MINS.
<br />Blair, Nebraska 7
<br />rre.l S
<br />February 23 1931
<br />7. SOCIAL SECURTIY NUMBER B
<br />Be. PLACE OF DEATH
<br />508 -30 -8187 H
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name /A'not inshkraon, give scree /and ^umber)
<br />St. Francis Medical Center ❑
<br />8c. CITY. TOWN OR LOCATION OF DEATH - 8
<br />8d. INSIDE CITY LJMITS B
<br />Be. COUNTY OF DEATH
<br />Grand Island Y
<br />Yee ® Na ❑ H
<br />Hall
<br />9a. RE DENCE - STATE g
<br />go. COUNTY 9
<br />9c. CRY. TOWN OR LOCATION 9
<br />9d. STREET AND NUMBER IMcluding2FP Cads/ 9
<br />9e. INSIDE CITY LBMT$
<br />Nebraska H
<br />Hall G
<br />Grand Island 5
<br />518 W 8th St., 68801 Y
<br />Yes 12 ❑
<br />- 10. RACE - (e.g, White. Black. American 1=7T7, .
<br />. ANCESTRY (e.g.. Itelien..Mexwan. German, ;;;i;7_
<br />lcl 1
<br />12. ❑ MARRIED ® WIDOWED 1
<br />13. NAME OF SPOUSE /e wde. givemaiidwn narrtel
<br />�g� (
<br />(SDecdY) N
<br />NEVER DIVORCED
<br />14a. USUAL OCCUPATION /Give kindol work done during mast 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed)
<br />a/ wgki life. even i/rekredl Elements 2ry o Secondary 10 -121 C
<br />16. FATHER -NAME FIRST MIDDLE LAST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harold (NMI) Miller Gladys (NMI) Reynolds
<br />' 1
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 08/06/1951 -- 1
<br />19a WFORMANT -NAME
<br />(Yes, no. or unk.) fit yes. give war and dates of servideal
<br />Yes Korean War 07/11/1953 G
<br />Geor ene K. Miller
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />518 W 8th St., Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE & LICENS NO. 21 a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME
<br />1254 �e,,,;a, ❑ Rene�al 03/06/2004 Grand Island City Cemetery
<br />2 9
<br />22a. FUNERAL �ne 2
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP(
<br />3213 W North Front St Grand Island, NE, 68803
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib1. AND (c)f I Interval between onset and death
<br />I
<br />PART r
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: _ I Ineral between onset and Beam
<br />I
<br />I
<br />11
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions to the death but not related PART III IF FEMALE WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED R MEDICAL
<br />PART ^ �yt" PREGNANCY IN THE PAST 3 MONTHS? IXAMINER OR CORONER?
<br />II � .. / 7 /" ` G (Ages 10 -541 Yes No p Yes No Yes No
<br />26a 26b. DATE OF INJURY (Mo. Day. Yr.) 26c. UR OF INJURY 26d.' DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined M
<br />Suicide Pending 260. INJURY AT WORK 261. PLAC&Q URY /S.tapypi farm. street factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Inveshgation Yes ❑ No[] olfiee b M7
<br />27a. DATE, OF DEATH (Ma. Day. Yr.) 28a. DATE SIGNED (Ate.. Day. Yr) 28b. TIME OF DEATH
<br />Zt e 6f < w
<br />t C5 ii;
<br />s 05 28c. PRONOUNCED DEAD (Mo.. Day, Yr) 28d. PRONOUNCED DEAD /Noun
<br />27b. DATE SIGNED (MO.. Day. Yr) IME OF DEATH
<br />/may i G
<br />M w� M
<br />,°. 27d. To the best el knowledge. death occur at ilia sme. an ace and due t0 the ° ° 28e. On the basis of examination end's irneadgaaon, in my opinion death occurred at
<br />causelsl staled. edged✓% ~ ° is the time, date and place and due to the cause(sl stated.
<br />Poo 'Signature and Title) ► (S' nature and Tdle
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH 30.a S ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO UNKNOWN El NO ❑ YES UCI NO
<br />31. NAME AND M ND. ,�s 2201 N Broadwel
<br />COUNTY Al
<br />Ghulam R. Mirza l Ave., Grand Island, NE 68803
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />30L REGIIISTRAR MAR 18 2004
<br />
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