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<br /> STATE Of NEBRASKA-DEPART1R�Ic'�Qf 4��A�.?N
<br /> 9 9 � +� i� i��/� BUREAU Of VITAL STA"?�L':�S �
<br /> i �r l,1 CERTIFICATE OF �;�,��;H ,.� .;;,.> �
<br /> DECEDENT-NAME FIRST MIDDIE UST ^ SfT rATt Qf C.A;M/µo.,Doy, ..) �
<br /> ,. Ernest Linwood Keene, Jr z m��e �, �1ove�h��- �a, ?g�� ' �"
<br /> RACE-(�.g.,Whih, blatk,Am�ricon ORIGIN/DESCENT(�.g.,Italian,M�rican, AGE-�o.rl�nhdoy UNC�"�� ? YEAR� CMOF.R : DAY �A'ff OF p?'FTN(hE� 't7.-ry,+..; �
<br /> Indion.�h.1(Sp�cily) G��mon,afcJ(Sp�ci/yl / (Yrc) MOS. ��AY:4! !?O�R$; N17�l:G. .
<br /> .. white S, unknown t�(`� aa 59 sb. J `,±- ; �, Jt��-�.e 3, 1922
<br /> CITT AND STATE OF BIRTM(I!nof in U.S.A., �}��` CITIZEN OF WMAT COUNTRY MARRIED,NEVER MAfi4; �, i N.4MF OF SVOUS�(1/wi0�a,�'da maid�n nnm�)
<br /> nam�counlry) �J� WIDOWED.DIV05CED(Sp*c�Fp; �
<br /> e. Rockland, [�lassachusetts 9. U.S.A. ,o marr.�ed ;,, Porothy ?Lnsen
<br /> SOCIAI SECURITY NUMBER USUAL OCCUPATION(Giw kind ol work don�during motl tLlN4�^.>F 9USINESS OR��+[tiJSFR'��-(3UW"`!i�f i.)E,A!%?
<br /> o/workin lifs,ar�n ilrahr�d) �
<br /> ,s.011-12•-:;54,' �,,. ]�aintenance ��1z�"� , �°ach�:zz�:rY I�a, T'a��
<br /> �_
<br /> C�TY,F�'1��tl 2+R LOCA1'1�'„'k�F DEATM ,INSII�?�:.I"f l6Ml�S HOSPITAL 4�OTHrS(Pi4STiTl�.:,^,N-N �nrc f'*^+o�+n eilhrr, �{�OS► 02 r+a,7.� ��c ��ppq,
<br /> T (Sp�cifrYa:� P+Vo p�.e tornsl��nd nYm4�) O��yar� . I£ ..x+. .� ��•n�f�pxN�l
<br /> Y a'.r.l_ ai..1� 1 S��P� �x. ;��$ ,y_t Id._ 'i:!-E ivi''4'.� 1 ��'.`-,�' f:�S' i d.. i fl r��i � y�
<br /> f'-----,. —._.------ ------- - — - .—�_.��--
<br /> �:'St�*EM.E�-STATE �COUNrY f�EY',, r.�fJ��' �"� ,Af�� k � �REETr 0 D N!i.4�,ER I�/S'AF L�T-LiMITS
<br /> Tr � . � .l�aa:•> -�ro ar Wr,)
<br /> 15a..VE�.11<iSi�S lib. �3::�. �;�, f '' .. f � 2 �ll'.,c �d. t�/? � �:,'",,; rJ��l ',li. /�. S
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<br /> fA3MER-�E�eA1s1£ F�p�$T a+�.f�.l�," ,.,,� . �i�e;:,!.;;;{-MAIDENhE,•1.NE ;�fSST �._... N�:Ce'�iE !,�.:i'
<br /> , , liv. Ernest Linwood K-�ene, �r i „ (liv.� i��1aY�y J MacV�illiams
<br /> WAS DECEASED EVER�N U.S.ARMED FORCES? INfORMANT-NAME-RELA110NSHIV-MAILING ADDRESS (STREEt OR R.f.D.NO.,CITY O�(OWN,STATE,III)
<br /> (`/�i.no,or�nLl UI yn,9rve war ond da�e�o!�erv¢!1
<br /> ,eYes/iN� II/12-31-42/12-5-45 ,9.Doroth Keene,wife,1521 West Sth,Grand Island,NE68801
<br /> BURIAI,Cremutiun,Removul CATE CEMETFRY OR CREMATORY-NM1E � � LOEATION CITY7R TOWN STATE
<br /> �� �3uria2 �ob IJov. 6 1 'c3� ��.1•lestlatrri i�Iei ori.a, Par�__ soa. r d
<br /> EMlAIMER-SIGNAiURE d IICENS� O. � FUNERAL HOME--NAMF AND ADDRE55 (STRFfT ON R.F.D.NO.,C�n'Op.,7OwH STArE, ��oOZ
<br /> c L� 1S1�dI1Q����• v
<br /> �����a�- ����������� zz. Livin ston—Son�aer ann's 05 �dest hoeni. St. , Grand/
<br /> DATE Of DEATH(Mo.,Day,Yr.) DATE SIGNED(Mo.Day,Yr.) MOUR OF DEATM
<br /> s.Z _ Z W
<br /> ��Z
<br /> �� z,,. November 4, 1981 :�o ��a 246 M
<br /> �a DATE SIGNED(Mo.,Day,Yi.) MOUR OF DEATH =�K PRONOUNCED DEAD PRONOUNCED DEAD(Hour)
<br /> yZ> ai<i.
<br /> �°� 2,b.Novemb er 9, 19 81 2,�. 2: 15 a. M �W Z o (Mo.,Day,r,.�
<br /> �`� 44c. 24
<br /> �°e io�M e..�or my knorl�dp�,d�a�h xe�rn al�h��ima,do��ond ploe�ond du��o rh� 0�0 On�th�ba�i�af�aa�nina�ion and/o.in ��iqarion,in y opinion d�aeh xeumd a�
<br /> o r cou�NO.�aNd. �
<br /> �t ^ � / � 0 o th�tirn�,da��ond plac�and du��e�h�cavw(il�toud.
<br /> 43d.f Siyno�rr�ond ii/f�/• r' '�"• �� '�/ '� .. 2�e.�Signo�ur�ond i�N.J� •
<br /> NAME AND ADDRESS OF CERTIFIE (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY)(�ypa or Prin�) C�HHOI
<br /> 25.Enri ueta A. Bellosillo,M.D. , VA Medical Center, 2201 N. Broadwell,Grand Island,NE
<br /> REGISTRAR DA ECEIVED BY REGISTRAR(Mo.,Day,Y..)
<br /> , /z�.�s;a�a,�..,► C2� � �`� " c�—� 2 ,�,f,'r�2 � �'�� ���
<br /> 27. IMMEDIATE CAUSE (ENTER ONL ON CAUSE PER LINE FOR(a),(b),AND(c)) i Inr•no1 b�n.•.n o���t ond dwM
<br /> PART j
<br /> ia� �li.oblastoma multiforme � Months
<br /> DUE TO,OR AS A CONSEQUENCE OF. ,��iA In��rvol�b�m.�n onm and dwrh
<br /> ,
<br /> ��1:Hf:,W`: • � , � .
<br /> (b) nrn� . " � i .
<br /> DUE TO,OR AS A CONSEOUENCE Of: , In�•nol b•w.•�on�•�a�d dwiA
<br /> Id
<br /> ►ART�TME�SIGNIfICANT CONDITIONS-Condi�ion�conhibutinp ro dw�h bu�no�r�laNd PA�T 111.If FEMALE,WAS THEIIE A AUTOiSY WAS CASE REfERRED TO MEDICAL
<br /> �� VREGNANCY IN TME PAST 3 MONTMSi (Sp�cily Y��or No/ E%AMINEA OR CORONER
<br /> lSp�cilr 1'��o�,{�)
<br /> Ye�❑ No❑ 48. N� 4:9.w�o�.�,„I�.v
<br /> ACCIDfNi,SUIGDE,MOMICIDE,UNOEi.. OATE OF INIURY(Mo.,Oay,Yr.l MOUR Oi INIURY DESCRI6E MOW INIURY OCCURRED � � �
<br /> OR►ENDING INVESTIGAiION.(Sp�ai/r)
<br /> 30a. 70b. 30c. M 30d.
<br /> INIURY AT WORK ►LACE Of INIURY-Ar Ao�n�,Iarm,�trNt,fodory, IOCATION STREET Oi R.F 0.No. C17Y OR TOWN SiATE
<br /> ISp�cilr Yn o.Ne1 o11ic�buildinp,��a lSp�ailrl
<br /> 3a. 3P�. 30 .
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<br /> .....�i...�.�.�....i...�.�.i.�Ar......n..u.,.,,.o.....�..l.�........
<br /> WHEN THIS CO,,�'Y CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> -S�ATE DEPART�IENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> A ,:TRUE COPY �:GF" AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> DEPARTMENT�,�.F'- HEALTH, BUREAU OF VITAL STATISTICS , WHICH
<br /> IS THE L;E�A� 'DEPOSITORY FOR VITAL RECORDS .
<br /> ' .
<br /> � ���
<br /> DTRECTOR OF VITAL STATI.STICS AND ASSISTAAIT STATE REGISTRAR
<br /> ��NCOLN, NESRASxA Issued November 18, 1981
<br /> ' �� ,.
<br /> LEGAL: Lot Five (5) Block Eiqht (8) , in Eonnie Brae Addition & that
<br /> part of vacated Monroe Street as shown in Ordinance 4842 recorded in �3ook
<br /> 20 , Page 448 , in the city af Granc� Island, Hall County, Nebraska
<br />
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