|
o R _n M N
<br />-G C
<br />Z
<br />N
<br />f
<br />*mw TH= cwv QmmS T11E I�AgED SE I HEAD i
<br />SYSTE;f4 R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RFC1
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAB_ J
<br />THE LEGAL DEPOSITORY FOR VITAL RECORD& - -_
<br />DATE OF ISSUANCE
<br />5/5/2004
<br />LINCOLN. NEBRASKA HEALTH Abp HIAN;
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SljtVF�F
<br />VITAL STATISTICS -
<br />r 1P V TTRTr a TP n>a nP A TTI4
<br />-04 04886
<br />,. DECEDENT -NAME FIRST MIDDLE LAST
<br />v
<br />G) �
<br />Q
<br />rn
<br />April 30, 2004
<br />4. CITY AND STATE OF BIRTH /H not in U.S.A.. name country)
<br />5a. AGE -Law Bktimday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />~
<br />{'
<br />M
<br />o
<br />rre.l 66
<br />M
<br />Cedar Rapids, Nebraska
<br />Accident F� Undetermined
<br />M
<br />rNa
<br />-D
<br />O
<br />A
<br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Ul
<br />8b. FACILITY - Name (trnotmseituddrn, give skeet and number/
<br />628 East Ashton Avenue
<br />❑ DOA ❑ Other (SPecdvl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS I
<br />8e. COUNTY OF DEATH
<br />O
<br />Yea N1 No 1:1
<br />m
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />Gl1
<br />9d. STREET AND NUMBER /lnclieng Zip Code)
<br />� N
<br />Nebraska
<br />r >-
<br />Grand Island
<br />628 East Ashton Ave. 68801
<br />�Y' s ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY fe.g.. Behan. Mexican. German, etc)
<br />13. NAME OF SPOUSE /If wife. give maiden name/
<br />etc.) (Specify) White
<br />Specify) American
<br />NEVER DIVORCED
<br />4
<br />M R
<br />14a, USUAL OCCUPATION /Give kiridof work dare during mast
<br />14b. KIND OF BUSINESS INDUSTRY
<br />SERVICES
<br />(Speciy only highest grade completed)
<br />Elementary Zen ro -121 College n -4 «s -1
<br />of working mile, even drea Meat Cutter
<br />Z
<br />AtflLE WITH
<br />_
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />10
<br />CH IS
<br />Frances Theewen
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />(Yes. no. or unk.) (d yes. give war and dates of services)
<br />YeS March 8,1957 March 7,1963
<br />-04 04886
<br />,. DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. O F DEATH /Month. Day. Yen)
<br />Daniel Francis Mahoney - -
<br />Male
<br />April 30, 2004
<br />4. CITY AND STATE OF BIRTH /H not in U.S.A.. name country)
<br />5a. AGE -Law Bktimday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH IMontr1. Day. Yen)
<br />5b. MoS. I DAYS
<br />So. HOURS I MINS.
<br />26b. DATE OF INJURY (two_ Day. Yr./
<br />rre.l 66
<br />August 17,1937
<br />Cedar Rapids, Nebraska
<br />Accident F� Undetermined
<br />M
<br />7. SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />HOSPRAL: ❑ Inpatient OTHER: ❑ Nursing Home
<br />50546 -1445
<br />26t PLACb OF INJUUR.Y iAt -- ,farm. street factory
<br />dlfiaccee wltlin4
<br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY - Name (trnotmseituddrn, give skeet and number/
<br />628 East Ashton Avenue
<br />❑ DOA ❑ Other (SPecdvl
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS I
<br />8e. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yea N1 No 1:1
<br />Half
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lnclieng Zip Code)
<br />INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />628 East Ashton Ave. 68801
<br />�Y' s ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY fe.g.. Behan. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /If wife. give maiden name/
<br />etc.) (Specify) White
<br />Specify) American
<br />NEVER DIVORCED
<br />Luc Schuele
<br />M R
<br />14a, USUAL OCCUPATION /Give kiridof work dare during mast
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Speciy only highest grade completed)
<br />Elementary Zen ro -121 College n -4 «s -1
<br />of working mile, even drea Meat Cutter
<br />Grocery Store
<br />-
<br />_
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. Mowig FIRST MIDDLE MAIDEN SURNAMIf
<br />Walter Mahoney
<br />Frances Theewen
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME
<br />(Yes. no. or unk.) (d yes. give war and dates of services)
<br />YeS March 8,1957 March 7,1963
<br />y aone y
<br />Luc Mahoney
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />628 East Ashton Avenue, Grand Island, Nebraska 68801
<br />20. EMBALMER - NA RE 8 LI E NO.
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 210.
<br />CEMETERY OR CREMATORY- NAME
<br />1071
<br />❑ Burial 1:1 Removal
<br />May 3, 2004
<br />Westlawn Crematory
<br />. FUNERAL HOME - NAME V
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home, LLC
<br />® Cremation 0 Donation
<br />Grand Island, Nebraska
<br />22b. tVNtHAL FIVMC AUUnCJJ IJ,ncc. vn n.r.v. ..v.. v... ...- ....---- - -, -.,
<br />2929 South Locust Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lab (b(, AND (c)) I Inttemat between onset and death
<br />PART
<br />(al / Interval between onset and death
<br />_ DUE TO, OR AS A CONSEQUENCE OF'
<br />I
<br />(b)
<br />Interval
<br />DUE TO, OR AS A CONSEOUENCE OF: between onset and death
<br />� I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Condition corarlbuting to the death but not related
<br />1 IF FEMALE, WAS THERE A
<br />24 AUTOPSY
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />PART
<br />TPREGNANCY IN THE PAST 3 MONTHS?
<br />II
<br />10-541 Yes n No M
<br />Yes n No Y
<br />Yes n No
<br />26a.
<br />26b. DATE OF INJURY (two_ Day. Yr./
<br />28c. HOUR OF INJURY
<br />121d DESCRIBE HOW INJURY OCCURRED
<br />Accident F� Undetermined
<br />M
<br />Suicide 11 Pending
<br />26e. INJURY AT WORK
<br />26t PLACb OF INJUUR.Y iAt -- ,farm. street factory
<br />dlfiaccee wltlin4
<br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a DATE OF DEATH (two.. Day. Yc)
<br />28a. DATE SIGNED (MO.. Day. Yr./ 28b. TIME OF DEATH
<br />April 30, 2004
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr) 27c. TIME OF DEATH
<br />g g 28c. PRONOUNCED DEAD /MO.. Day, Yr.) 2ed. PRONOUNCED DEAD (Foal
<br />6:15 p M
<br />s�� M
<br />° < 27d. To the best d my knowleage. death occurred at the time, date and place and due to the
<br />~
<br />go 28e. On the basis of exarninaEOn antl�or nvestgation, in my opinion death occurred at
<br />causelc; stated
<br />v a Ume lima date and place and due o the causefs) stated.
<br />- /�1
<br />IS' nature and Title ►
<br />(Signature arM TNe 0
<br />29. DID TOBACCO USE CONTRIBU E DEATH? A HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES IR NO ❑ ❑
<br />YES r NO ❑ YES NO
<br />31. NAMEANUADDHESSUHUtHimlcn .... .,,...• -••- "••- °- -• - - - -•
<br />Jeffrey R. King, MD 729 N Custer Av, Grand Island, NE 68803
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr/
<br />- 42004
<br />LOT 9, BLOCK 6, MEVES FIRST ADDITION TO THE CITY OF
<br />GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />
|