|
�� �
<br /> � � � ^� � , f, +
<br /> c� r-; � 1"'i
<br /> � ` ' � � � T` � '-+'
<br /> � <.n
<br /> _ � v *M ,4' � - ,"° �.�� � c.p O -i "f� �
<br /> 7 [ � �
<br /> � n. � � T= t a � � g � � G � �
<br /> ,
<br /> �-
<br /> O �r ` i S _`. ? � � � � � '� � Rl � t11
<br /> f,� '� �� � � � ,, r� q� � p�`':�: N O ��*t CD �
<br /> � � �i ' � �, ` z i--' �'
<br /> �' ' ' �/` i , � r,'t c
<br /> � � I� i`, N �� � d y 1 ��"'•� 'T_l 1'n_ ...��7 � �
<br /> � ��
<br /> o " � y i ; > ' � r- �n c.o � 1
<br /> � �
<br /> � a , � �� � r+
<br /> �
<br /> ' � 93 109 �6 "7 � � ; � � } ,.'.. � ...� � o �
<br /> W � -� tn �1
<br /> o cn
<br /> �
<br /> LOT SIX (6) , AMICK ACRES EAST SUBDIVISION HALL COUNTY, NEBRASKA
<br /> � tt
<br /> wr�v n�rs coPr cA►�s nf wusEV s�u oF n��eRi��u t��ao d�v sE�s ��j �
<br /> SYSTEM,IT CERT�S TF�BELOW TO BE A TRUE COPY OF THE,DI�IAf$L�##l1�LE W/TH
<br /> THE NEBRASKA FIEALTH AND HUMAN SERIRCES SYSTEM,VITA�_�_ . -- - ..,..}:._.._.,,�.,�,e r-_...4 r_w. ...
<br /> TFIE L�f�dL�DEPOS/TORY FOR VITAL RECORDS. -: � �
<br /> DATE OF/SSUANCE - __ � � :: �
<br /> __�1�����AK[.EIE,�c�OPER
<br /> ' �Y�� "�_AS�I�ANT,FIA�REts7STRAR !
<br /> LINCOLN,Nl�FlRASKA HEALTifi4�llD.��IIC��'SYSTEM
<br /> � STAlE OF NEBRASKA-DEPAR'['Mf1J't OF HBALTH AND HUMA1�kt�ES:FH7�AND SIIPPORT
<br /> V1TAL STA?LS17CS - -
<br /> . CERTIFICATE OF DEATH �
<br /> 1.DECEDENT-NAME FIFST MIDDLE UST 2.SEX 3.DATE OF DEATH /ManM Day Year/
<br /> Philli D. Johnson Male October 1 1
<br /> �.CITY AND STATE OF BIRTH Illnd'n U.S.A..Mms cpmhyl Sa.AGE-Lest Birthday UNDEH 1 VEAR UNDER t DAV 6.DATE OF BIRTH �MpnEh.Day.Year/
<br /> Hastings, Nebraska ��rs� 51 s� Mos w�s Sc.HWRS� M�NS Janua 20
<br /> 7.SOCIAL SECURTIY NUMBER Ba.PIACE OF DEATM �.
<br /> 508-56-0738 Hos�T��: ❑ InpetieM OTHER � NurSmgHOme
<br /> �p.FACiUTV-Name /M nni nsfiAam,piw shssf end numba/ � ER OulpetieM� �Residence
<br /> 2409 W. 6th Street � °OA � °"'°`'�""'
<br /> !c.CITV.TOWN OR LOCATION OF DEATH Bd.INSIOE CITV UMITS Be.CWNTV OF DEATH � �
<br /> Hastin s � Y�� � ❑ ..�.. , -. -- --
<br /> 9�.FESIDENCE-STATE 9b.COUNTV 9c.CRV.TOWN OR LOCATION 9d.STREET AND NUMBER /Iric/uding Zi0 CoOel 9e.INSIDE GTV LIMITS
<br /> Nebraska Adams Hastin s 2 '`� "°�
<br /> 10.RACE-Ie.p.,lNhib.Blsck.Ameriwn Mian. 11.ANCESTRV le.g..I41ian.Msxban.German,e�) t 12.a MARRIED �W IDOWED 13.NAME OF SPOUSE /ll wAe.give maiden namel
<br /> ����S�fi') (��� NEVER DIVORCED
<br /> White German Danish
<br /> iN.USUALOCCUPATON /Givek'wMdrwkdd»dvingmoal r� 1tb.KINDOFBUSINESSINDUSTRV O 15.EWCATION (SpxAyoNyhigMqpaAacompNlW�
<br /> a»wkinyaro..»ns..w.e� � � �o� � flsm�nuryaS�calWarylO-t2) ' CdMpel�-�a5•1
<br /> Owner/0 erator Land Surve in +
<br /> 16.FATHEA-NRME FIRS1 MIDDLE UST /7.MOTMEF FIRST MIDOLE MAIDEN SURNAME
<br /> Stanle 33. Johnson Roberta I. Phillips
<br /> • q.NAS DECEASED EVER IN U.S.ARMEO FORCES? t9a.INFORMAMT-NAME !
<br /> i..............
<br /> IVes.no.a unk.�. (N yw.pw wa�W tlaNS d�rvicesl ..
<br /> Farhar
<br /> 19E.INFORMANT MAIIING AODHESS ISTREET OR R.F.D.NO..GTY OR TOWN.STA .ZIP� .
<br /> 2�5 A ricot Lane. Doni han Neb
<br /> 20.EMBALMER-SIGNA7URE d LICENSE NO. 2t a.METHOD OF qSPOSI`.ION 21b.DATE 21c CEMETERV OR CREMATOAV�NAME
<br /> No Embalming ❑s���a� ❑���a� r �S CPntra l NF. Cxemation -
<br /> 22a.FUNERAL HOME-NAME 21d.CEMETERY OR CREMATORY l(xATION CITV OA TOWN STATE
<br /> Livin ston-Butler-Volland F.H. �c`8�°� ❑°°°a�'°�' ,
<br /> 22�.FUNERAL HOME ADDRESS (STREET OR R.F.D.NO.CITY OR TpWN.STATE.21P� �
<br /> 1225 N. Elm Street Hastin s Neb
<br /> 23. IMMEDIATE CAUSE (EN7ER ONLY ONE CAUSE PER LINE FOR IaL(bl.AND�cp � IMerval benvcen onsel antl tlealn
<br /> PART �
<br /> , Cardiac Arrest �
<br /> �e, �
<br /> OUE TO,OR AS A CONSEOUENCE OF� i Irnerval belween onsei antl tleatn
<br /> i
<br /> ��i Severe .I�,poglycemia �__ �
<br /> W[TO.OR AS h CONSEUUENCE OF� � �� � . � � Intervai Oetween onset and aeatn
<br /> i
<br /> ��� I
<br /> OTNEP SIGNIFICANT CONDI7pNS-Contlilwns cdHriWUng�o ihe death Eul ral relate0 ' PAflT III IF FEMALE.WAS THERE A 24 AUTOPSV 25.WAS CASE REFERRED 70 MEDICAL
<br /> PART PREGNANCV IN THE PAST 3 AAONTHS� E%AMINER OR CORONER�
<br /> N
<br /> (Ages t0-54� Ves No Ves No Ves No
<br /> 28a. 26b.DATE OF INJURV (MO..Dey.Yr.J 26c.HOUR OF INJUHV 26d.DESCRIBE FIOW INJUR`I OCCURHED
<br /> q.�CCidMt � UMelerrtwned M . . .
<br /> � SuicMe � Pendhg YW.INJURV AT WORK 261.P�,qCE QF INJURV-At home,larm,slreet lactory 26g.:OCATION STREET OR R.F.D.NO. CITV OR TOWN STA7E
<br /> dfce bwlding.etc. /Spaciyl I
<br /> � �w�,,,�� Invesugalbn �,5❑ Na❑ 2409 W. 6th St Hastin s NE
<br /> 27a.DATE OF DEATH /MO.Osy Yc) 28a.DAiE SIGNED /MO..Day.vr.� 2Bb 71ME OF DEATH i''��.
<br /> <' 10-23-98 10:00 p M I
<br /> �a� s��
<br /> 27b.DATE SIGNED (A1o.Day Yr/ 27e.TIME OF DEATH �6 g Y 28t.PAONOUNCED DEAD /MO_Day.YrJ 28d.PRONOUNCEO DEAD /Fbutl �
<br /> o�� .M �W�� 10-22-70 / :OO r M
<br /> � 27tl.To Ihe beffi of my knowleUge.OeaM acurred at the nrtN,da18 aM dace and Eue to the °�� 28e.On Mie Dasis ol examinatron anC�w mvestigauon,in my opinion Oeath occurre0 ai
<br /> eauselsl s�ated. ~° a Me time,tlate aM place E to the cau s ated.
<br /> �S naNre and Tille► IS nature antl Title►
<br /> 79.pID TpBACCO USE CONTPoBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CO SENT GRANTED9
<br /> � VES � NO X❑ UNKNOWN � �ES O NO � VES � NO
<br /> 31.NAME AND ADDRESS OF CERTIFIER IPHVSICIAN,CORONER'S PHVSICIAN OR COUNN ATTORNEVI l7Ype a Prinfl I��
<br /> S. Colin Palm, Deput Co. Atto ne , PO Box 71, Hastin s Nebraska 68901
<br /> 32a.REGISTRAR 7�b.MTE i1LED BY 9E�TAAR_ /Ya.Ory.Y�
<br />; _ �_ , . �
<br /> 0 29 I
<br />
|