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194 DOUGLAS COUNTY HEALTH DEPARTMENT 26`7603
<br />2 0 0 4 0 6 5 4 5 VITAL STATISTICS SECTION — OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />)
<br />)
<br />)
<br />D
<br />D
<br />D
<br />5
<br />D
<br />D
<br />0
<br />1
<br />D
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />;0
<br />n
<br />c)
<br />Male
<br />June 5, 1994
<br />4. CRY AND STATE OF BIRTH / /rof in USA. iwne Cawlby/ 5a AGE - Last BsldaY
<br />UNDER 1 YEM
<br />UNDER 1 DAY
<br />6� 6
<br />k10S DAYS
<br />5c. HOURS' MNS
<br />n
<br />s
<br />D
<br />8a PUCE OF DEATH
<br />HHOSPrrnL �C] `sae" OTHER ❑ ".-",g Hcnhe
<br />031-12-3599
<br />M
<br />8b FACILITY - Name IN nuf nshkoo L 9v streA aro /brnberl
<br />VA Medical Center
<br />❑ DOA ❑ Otr,e. lsoerwt
<br />z
<br />So INSIDE CRY LIMITS
<br />Ile COUNTY OF DEATH
<br />Omaha
<br />:1
<br />Yes ® NO ❑
<br />Douglas
<br />9a. RESIDENCE STATE
<br />�
<br />r)
<br />9d. STREET AND NUMBER (kK'k dig Zq Cal% 8 801
<br />9e INSIDE CITY LIMITS
<br />�
<br />Nebraska
<br />Hall
<br />Grand Island
<br />607 Ivy Hall Place
<br />Yes® Na❑
<br />N -s
<br />10 RACE - leg., White . Blacx Amer VK*ari
<br />M
<br />rn
<br />D
<br />N
<br />cn
<br />etc'15pecAyl White
<br />( �") Finland /German
<br />I
<br />NEVER DIVORCED
<br />�. -� Ingrid Lembcke
<br />_ _
<br />-� m
<br />o chi.
<br />ElemenfaY ar SewWan, 10 121 CoteW I1 -4 a 5.1
<br />W. even /refredl
<br />red Militar
<br />Government
<br />4
<br />F14.USUALOCCUPATION
<br />AME FIRST MIDDLE LAST 17
<br />CD
<br />Thomas Joseph Girkout
<br />Constance E. Zerofski
<br />ASED EVER KN US ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />nkl IN yes. 9w war and dales of sere cesl
<br />Yes 11 -23- 43/06 -30 -70
<br />VA Medical Center
<br />O
<br />19b INFORMANT MAILING ADDRESS ISTREET OR RF D NO., CITY OR TOWN. STATE. ZIP)
<br />K `
<br />4101 Woolworth Ave. Omaha, NE 68105
<br />20. EM MER - SIGNATURE 6 YqEMSE 140.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY - NAME
<br />�f
<br />rowx F"
<br />x
<br />A �
<br />-
<br />o
<br />Go
<br />22a. FUNS - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE
<br />A fel- Butler- Geddes
<br />❑°trn"°h ❑Da'al°n
<br />3
<br />rn
<br />1123 West Second Street Grand Island, Nebraska 68801 -5899
<br />I Interval between onset and death
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). IbL AND Icll
<br />PART I
<br />1 lal A$ tole Immediate
<br />A CONSEQENCE OF Interval belween onset and death
<br />DUE TO. OR AS U
<br />Ibl 6 Weeks
<br />DUE TO. OR AS A CONSECUENCE OF I Mhlerval bethaeen onset and dear,
<br />I
<br />10 —
<br />OTHER SIGNIFICANT CONDITIONS - Conditions conlrft q to the death but not related PART
<br />MI IF FEMALE, WAS T A 24
<br />0
<br />en
<br />cl'I
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER"'
<br />I
<br />(Ages
<br />10 -541 Yes No
<br />Ye
<br />Yes No
<br />26a.
<br />281, DATE OF HAIRY /W. Dry. Yr/
<br />26c. FIWR OF WJURY
<br />2
<br />❑ Accd.0 ❑ Undelemm�ed
<br />M
<br />❑ Suhcde ❑ perdvg
<br />26e. PWLIRY AT WORK
<br />194 DOUGLAS COUNTY HEALTH DEPARTMENT 26`7603
<br />2 0 0 4 0 6 5 4 5 VITAL STATISTICS SECTION — OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />)
<br />)
<br />)
<br />D
<br />D
<br />D
<br />5
<br />D
<br />D
<br />0
<br />1
<br />D
<br />This certifies this document to be a true copy of an original record on file with Vital
<br />Statistics,-Douglas'County Health Department, Omaha, Nebraska. Certified copies must have
<br />a raised seal in the -area to the left. Reproductions of this green certificate are not
<br />legal copies. AW-40
<br />Date issued: jW 1 �7 ►yy� Registrar:
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /4uhMh Dry Yowl
<br />Thomas Joseph Girkout Jr.
<br />Male
<br />June 5, 1994
<br />4. CRY AND STATE OF BIRTH / /rof in USA. iwne Cawlby/ 5a AGE - Last BsldaY
<br />UNDER 1 YEM
<br />UNDER 1 DAY
<br />6, DATE OF BIRTH /hhn/t Day Y.1
<br />k10S DAYS
<br />5c. HOURS' MNS
<br />(Y,sl 67 15"
<br />Colon, Panama
<br />November 12, 1926
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PUCE OF DEATH
<br />HHOSPrrnL �C] `sae" OTHER ❑ ".-",g Hcnhe
<br />031-12-3599
<br />❑ ER Outpatient ❑ Res,dence
<br />8b FACILITY - Name IN nuf nshkoo L 9v streA aro /brnberl
<br />VA Medical Center
<br />❑ DOA ❑ Otr,e. lsoerwt
<br />Sc CITY TOWN OR LOCATION OF DEATH
<br />So INSIDE CRY LIMITS
<br />Ile COUNTY OF DEATH
<br />Omaha
<br />:1
<br />Yes ® NO ❑
<br />Douglas
<br />9a. RESIDENCE STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (kK'k dig Zq Cal% 8 801
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />607 Ivy Hall Place
<br />Yes® Na❑
<br />10 RACE - leg., White . Blacx Amer VK*ari
<br />11. ANCESTRY le.g.. Ilallan. Mexican German, elcl
<br />12. ® MARRED ❑ WIDOWED 13 NAME OF SPOUSE It w1fe 9W Madan name)
<br />etc'15pecAyl White
<br />( �") Finland /German
<br />I
<br />NEVER DIVORCED
<br />�. -� Ingrid Lembcke
<br />UPATION (Gne kind of -0rk dne dk"W most 140
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpecdy ony �M grade Conhp OWM
<br />ElemenfaY ar SewWan, 10 121 CoteW I1 -4 a 5.1
<br />W. even /refredl
<br />red Militar
<br />Government
<br />4
<br />F14.USUALOCCUPATION
<br />AME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MtODLE MAIDEN SURNAME
<br />Thomas Joseph Girkout
<br />Constance E. Zerofski
<br />ASED EVER KN US ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />nkl IN yes. 9w war and dales of sere cesl
<br />Yes 11 -23- 43/06 -30 -70
<br />VA Medical Center
<br />19b INFORMANT MAILING ADDRESS ISTREET OR RF D NO., CITY OR TOWN. STATE. ZIP)
<br />4101 Woolworth Ave. Omaha, NE 68105
<br />20. EM MER - SIGNATURE 6 YqEMSE 140.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY - NAME
<br />rowx F"
<br />®B„aI ❑Removal
<br />June 8, 1994 IFt.
<br />McPherson Nat. Cem.
<br />22a. FUNS - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE
<br />A fel- Butler- Geddes
<br />❑°trn"°h ❑Da'al°n
<br />Maxwell, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR FLV D. NO -. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street Grand Island, Nebraska 68801 -5899
<br />I Interval between onset and death
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). IbL AND Icll
<br />PART I
<br />1 lal A$ tole Immediate
<br />A CONSEQENCE OF Interval belween onset and death
<br />DUE TO. OR AS U
<br />Ibl 6 Weeks
<br />DUE TO. OR AS A CONSECUENCE OF I Mhlerval bethaeen onset and dear,
<br />I
<br />10 —
<br />OTHER SIGNIFICANT CONDITIONS - Conditions conlrft q to the death but not related PART
<br />MI IF FEMALE, WAS T A 24
<br />AUTOPSY
<br />25. WAS CASE REFEi;pED TO 41EDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER"'
<br />I
<br />(Ages
<br />10 -541 Yes No
<br />Ye
<br />Yes No
<br />26a.
<br />281, DATE OF HAIRY /W. Dry. Yr/
<br />26c. FIWR OF WJURY
<br />2
<br />❑ Accd.0 ❑ Undelemm�ed
<br />M
<br />❑ Suhcde ❑ perdvg
<br />26e. PWLIRY AT WORK
<br />261. PLACE QF CRY .Farm. seeel taOdny
<br />26g. LOCATION STREET OR RF.D. NO. CRY OR TOWN STATE
<br />❑ H.—KI. aniressgaMm
<br />Yes ❑ No 1:1
<br />dFce Mad n4 //
<br />27a DATE OF DEATH (W. Day. Yr.. J
<br />28a. DATE SIGNED (W. Day. Y+.1
<br />28b TIME OF DEATH
<br />June 5 1994
<br />M
<br />27D DATE SIGNED /W. Day Yrl
<br />27c. TINE OF DEATH
<br />28c PRONOUNCED DEAD lW.. Day Yr!
<br />28d PRONOUNCED DEAD /Hanl
<br />June 10 19W
<br />5:07 P.M. M¢_°
<br />M
<br />8 F
<br /><
<br />° o °
<br />27d To the best of my,*t4w1eG*' death Occurred at the tree, dale and pace and due to the
<br />28e. On the basis of examahanon and or amsegaam, n my opinion death xcure0 at
<br />causeisi SIAVA ' - a
<br />ko`
<br />the bme, dale and pace and due to the cause(s) Staled.
<br />. ��i ` s Gre L Wiedel M.D
<br />eard TMe ►
<br />29 DID TOBACCO US TE TO THE DEATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30-b WAS CONSENT GRANTED'
<br />ES 'J o� NO i y 1 1 3'.1 ; UNKNONM ,
<br />❑ YES--
<br />❑ YES ® NO
<br />❑ YES ❑ NO
<br />31 NAME AND ADDRE OF CERTIFIER (PHYSICIAN, CORONER'S PHYK.IAN OR COUNTY AT70RNEYI (Type a PnM
<br />68105
<br />Pregory, U-"Wiede , ^M.D. , VA Medical Center, 4101 Woolworth Ave. Omaha, NE
<br />32a REGISTRAR +
<br />32D DATE FM.ED BV iSTRAR f � y Yr)
<br />N 1994
<br />This certifies this document to be a true copy of an original record on file with Vital
<br />Statistics,-Douglas'County Health Department, Omaha, Nebraska. Certified copies must have
<br />a raised seal in the -area to the left. Reproductions of this green certificate are not
<br />legal copies. AW-40
<br />Date issued: jW 1 �7 ►yy� Registrar:
<br />
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