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WHEN THlS COPY CARR/ES THE RA/SED SEAL OP THE NEBRASKA STAT�DEP�R�';t�f'.�'f%!.; _
<br /> /T CERT/F/ES THE BELOW TO BE A TRUE COPY OP AN OR/O/NAL RECORL��@�Ff��,',�����'E
<br /> D,EPARTMa�NT OP HEALTH,BUREAU OF V/TAL STAT/ST/CS, WHlCH 13 TN��/���OR
<br /> V/TAL RfCOROS. __
<br /> DATE Of/SSUANCE g g 1119 7 8 =__ _ ;-� ����
<br /> ��,�
<br /> JAN 61997 as� � -
<br /> 4- � R.47�
<br /> ,1/NGOLN NEBRASKA______._ _ ___ NEBRASKA A� �FflEAL'FH
<br /> -- ----
<br /> -:- - - -
<br /> - - -
<br /> � STATE OF NEBRASKA-DEPAHTMENT OF HEAt-�}I-_.__'_..`__ < -
<br /> BUREAU OF VITAL ST.ATISTICS -='
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT-NAME FIHS7 MIDDLE US7 2.SE7C 3.DATE OF DEATH /MOnth.Oay.YeerJ
<br /> Dorothy Mae Roach Female December 18, 1996
<br /> 4.CITV AND STATE OF BIRTH /Mnd'n US.A..name counhy/ Sa.AGE-Lasl BiNMay UNDER 1 VEAR UNDER 1 DAV 6.DATE OF BIRTH /MOnEh,Day YeaiJ
<br /> Rockville, Nebraska ��n� 66 5°_w°s. i DAVS s�.HOUas� MINS May 27, 1930
<br /> 7.SOCIAL SECURTIV NUMBER Ba.PUCE OF DEATH
<br /> 508-32-9020 �sPRn�: ❑ i�oee«n OTHER � NwsingHOme
<br /> � -
<br /> 8b.FACIUTY.Name � (Mnotiny6�Wtlq�,gmrafnMaMnumbsrl � ER'ONpatlenl � ResiCence
<br /> .
<br /> 621 S. Clark ❑ �A ❑ a,�,��.,ti,
<br /> &.CITY.TOWN OR IOCATION OF OEATH 8d.INSIDE CITY LIMITS Be.CWNTV OF OEATH
<br /> Grand I s land ,,,, �,,,, � Hal l
<br /> 9a.RESIDENCE-STATE 9D.COUNTY 9t.CRV.TOWN OR LOCATION 9d.STREET AND NUMBER /lnNudlrgZ'ip Code� 9e.INSIDE CfTV LIMRS
<br /> Nebraska Hall Grand Island 621. S. Clark 68801 ,.„� ��
<br /> 10.RACE-�e.q.,Whita.&ack.Amsricen Intlien. 11.ANCESTRV(e.g..llelian.Msxic�n,(�mm�,Nc) 12.�MARRIED a WIDOWED 13.NAME OF SPOUSE (N wile.9^'s��^^�^bl
<br /> °'c�is°°`n�i �S°"n�i U� NEVER DIVORCED Lester J. RoaCh
<br /> White American
<br /> 1N.USUAL OCCUPATION /Give kiMd x�ork dprs du�'wg mpsf 1ID.KIND OF BUSINESS INWSTRV 15.EDUCATION �Spec�iy oMy Mghss�gratle cpnpleled)
<br /> d swn X relire�l Ekment2ry pr$ecpryary(0-12� ' CoNSge(�-a w 5�1
<br /> �a�ntenance ,�j Government Building �� 12 �
<br /> 16.FATHER-NAME FIRST MIODLE UST 17.MOTHER FIRST MIDDLE MAIDEN SUFNAME
<br /> Victor NMN Grudzinski Clara NMN Ziola
<br /> 18.WAS DECEASED EVEF IN U.S.ARMED FORCES9 19a INFORMANT-NAME
<br /> (Ves.no.a unk.) �M yes.give war antl tlates d servieaa)
<br /> NO ---- Lester Roach
<br /> t9G.INFORMANT MAIIING ADORESS (STREET OR R.F.D.NO..CITY OR TOWN.STATE.ZIP�
<br /> Clark Grand Island, Nebraska 68801
<br /> Z0. AL -SIGNAT E 8 L E N . � �/ 21 a.MEfMOD OF qSPp$ITION 21b.DATE 27c CEMETERY OH CREMATORV�NAME
<br /> � �ei,,;,, ❑,�,�,�„ Dec. 21,1996 Grand Island City Cemetery
<br /> 22 NERAL HOME-NAME 21tl.CEMETERV OR CREMATORV LOCATION CITV OR TOWN STATE
<br /> Livingston-Sonder�►ann F.H. ❑�� ❑�� Grand Island, Nebraska
<br /> 22p.FUNEiiAL HOME ADDRESS (STREET OR RF.D.NO..CITV OR TOWN.STATE,ZIP)
<br /> 505 West Koenig, Grand Island, Nebraska 68801
<br /> 23. IMMEDIA7E CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR(a61�1.�D(cp I NNerval belween onaet arW Eeatn
<br /> PART I
<br /> � �a� Cardiac Arres t � Unknown
<br /> DUE TO.ON AS A CONSEQUENCE OF: i Interval Detween orme�and tleaM
<br /> I
<br /> � Lung cancer � Unknown
<br /> � - �
<br /> DUE TO.OR AS A CONSEOUENCE OF� I IMerval between onset antl death
<br /> �
<br /> Ic� �
<br /> I
<br /> OTHEH SIGNIFICANT CONqT10NS-GOrWilqnS CaXridA'1p IO C�B 0lMh btR rql re1Metl PART 111 If FEMAlE.�NAS THcRE A a AUTar aY Q$.WAS CA,^.E REFFARED TO 1dEOICAL
<br /> PART PREGNANCY IN THE PAST 3 MONTHS? �� �XAMINER OR CORONER7
<br /> II
<br /> (Agss10-54� Yes No V85 No Vas No
<br /> 26a. 28b.DATE OF MIJUHV (Ab..p�y,Yi/ 28c.HOUp OF MUUFV 28A.DESCRIBE MOW INJURV OCCURRED
<br /> � ACCidBM � UnOSlerrtnnsd M
<br /> � SuiciOe � Pentlirq 28e.INJURV AT VJORK 281.PUCE OF�INQ,JNUcRV��homs,hrm,street facby 26g.LOCATION STREET OR R.F.D.NO. CITV pR TOWN STATE
<br /> o16ce buad sjg
<br /> � HomiciCS InvesUgetqn yy❑ p�p❑
<br /> 27a.DATE OF DEATH /Ab..Day.Yr./ 28a.DATE SIGNED (MO..Day.vr.l 28b.T ME OF DEATH
<br /> X / K �ound at
<br /> a� a��� �.?- --96 . M
<br /> �� 27D.DATE SIGNED /Ma.Day.Yr./ 27c.TIME OF DEATH � 28c.PRONOUNCED DEAD /MO..Day,Yr./ 28d.PRONWNCED DEAD /Iburl
<br /> °�� 27d.To ms Dsst d my kmwlWqe.d��occumd a IM Yrt»,dqe uM d�u and dus ro ths M °��� 2BS.On ths beeia d�xamineUOn aMra irweppe0on.in m • .. M
<br /> �u y opnbn dsaM occ tl
<br /> uuae�s)aUtetl. � tM 6me,deM md plece antl Aus 10 Me eawe�a�s1aNd.
<br /> and TIMs uM TNN
<br /> 29.DiD TOBACCO USE CONTRIBUTE TO THE DEATH4 30.s HAS OROAN OR TISSUE DONATpN BEEN CONSIDERED? 30.b WAS CONSEM OHANTED?
<br /> � VES � NO �X UNKNOWN � � VES � NO � � VES � NO
<br /> 31.NAME AND ADDRESS OF CERTIFIER�PHVSICIAN,CORONER'S PHYSICIAN OR CWNTY ATTORNEV� (Typs orPnvMi
<br /> Sgt . L . Lessig Grand Island Police Department
<br /> 32a REGISTRAR 32G.DATE i ILE�Y BEGIST�R ��Qy Yr./
<br /> J N ��
<br /> � ` .
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