|
WHEN TM COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH A ES
<br />SYSTEM !! CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE 1M
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM_ IE --MICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />3�
<br />DATE OF ISSUANCE
<br />lAM EYE. CO�P�R
<br />10/7/2004
<br />200411529 A TAIYrSTA€€ BEG1STRAR
<br />LINCOLN, NEBRASKA HEALTH AA
<br />/KlMAN SERVICES S1F3TE1N .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMJQI SERY7EES F� AND - .SUPPORT
<br />vrrAL sTAnsncs _ V O 4 10834
<br />CERTIFICATE OF DEATM -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEC 3. DATE OF DEATH /Mont. Day. Year)
<br />Marvin Laverne Johnson Mali' rSeptember 24, 2004
<br />4. CRY AND STATE OF BIRTH /It not n U.S.A.. name county/ 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Mont. Day. Year)
<br />(Vrs.l Sb. MOS. DAYS Sc. HOURS' MINS.
<br />Broken Bow, Nebraska 74 August 16, 1930
<br />7. SOCIAL SECURTIY NUMBER
<br />28a. DATE SIGNED /Md.. Day. Yr.)
<br />°
<br />Be. PLACE OF DEATH
<br />X11
<br />Cy
<br />28e. On the basis of examination and,or inv sti
<br />to, 1,fim time, date and place ario t ause s
<br />HOSPRAL: ❑ Inpatient
<br />❑ ER Outpatient
<br />OTHER: ❑ Nursing Home
<br />® Residence
<br />Sb. FACILITY -Name (Nnottshfuton, give sorest and numbed
<br />2314 N. Grand Island Ave.
<br />rn
<br />C
<br />='
<br />m cn C
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />`,>
<br />c7 co
<br />o -i
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® Nd ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inc/udtg Zp Code68803
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2314
<br />N. Grand Island Ave.
<br />Yee ®- ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g..
<br />hallan. Mexican, German, etc)
<br />12. ® MARRIED " ❑ WIDOWED
<br />13. NAME OF SPOUSE /t wife. give maiden name)
<br />etc.) (Specify)
<br />White
<br />M
<br />A
<br />to
<br />Bernice Farrow
<br />14a. USUAL OCCUPATION /Give kind of work dare dung most
<br />C
<br />-< c
<br />15. EDUCATION (Specify only highest grade completed)
<br />W working hh, even if retired)
<br />Security Guard
<br />NE. Veterans Home
<br />�n{ Mary a SBCOnJJary 10 -124 - College 11 -4 or 5.1
<br />`JtLl Grade
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST
<br />MIDDLE MAIDEN SURNAME
<br />3C
<br />Johnson
<br />Frances
<br />•/
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />o
<br />�+
<br />(Yee. no. or unk.) (If yes. give war and dates of services)
<br />y
<br />f
<br />Rex Johnson
<br />o
<br />r n
<br />00
<br />cr,
<br />.t
<br />WHEN TM COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH A ES
<br />SYSTEM !! CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE 1M
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM_ IE --MICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />3�
<br />DATE OF ISSUANCE
<br />lAM EYE. CO�P�R
<br />10/7/2004
<br />200411529 A TAIYrSTA€€ BEG1STRAR
<br />LINCOLN, NEBRASKA HEALTH AA
<br />/KlMAN SERVICES S1F3TE1N .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMJQI SERY7EES F� AND - .SUPPORT
<br />vrrAL sTAnsncs _ V O 4 10834
<br />CERTIFICATE OF DEATM -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEC 3. DATE OF DEATH /Mont. Day. Year)
<br />Marvin Laverne Johnson Mali' rSeptember 24, 2004
<br />4. CRY AND STATE OF BIRTH /It not n U.S.A.. name county/ 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Mont. Day. Year)
<br />(Vrs.l Sb. MOS. DAYS Sc. HOURS' MINS.
<br />Broken Bow, Nebraska 74 August 16, 1930
<br />7. SOCIAL SECURTIY NUMBER
<br />28a. DATE SIGNED /Md.. Day. Yr.)
<br />°
<br />Be. PLACE OF DEATH
<br />28c. PRONOUNCED DEAD /MO.. Day, Yr.)
<br />-9/24/04
<br />507 -24 -5939
<br />28e. On the basis of examination and,or inv sti
<br />to, 1,fim time, date and place ario t ause s
<br />HOSPRAL: ❑ Inpatient
<br />❑ ER Outpatient
<br />OTHER: ❑ Nursing Home
<br />® Residence
<br />Sb. FACILITY -Name (Nnottshfuton, give sorest and numbed
<br />2314 N. Grand Island Ave.
<br />❑ DOA
<br />❑ Other fSpecdy)
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />So. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® Nd ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Inc/udtg Zp Code68803
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2314
<br />N. Grand Island Ave.
<br />Yee ®- ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g..
<br />hallan. Mexican, German, etc)
<br />12. ® MARRIED " ❑ WIDOWED
<br />13. NAME OF SPOUSE /t wife. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />MAR
<br />Bernice Farrow
<br />14a. USUAL OCCUPATION /Give kind of work dare dung most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />W working hh, even if retired)
<br />Security Guard
<br />NE. Veterans Home
<br />�n{ Mary a SBCOnJJary 10 -124 - College 11 -4 or 5.1
<br />`JtLl Grade
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST
<br />MIDDLE MAIDEN SURNAME
<br />Andrew
<br />Johnson
<br />Frances
<br />Govier
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yee. no. or unk.) (If yes. give war and dates of services)
<br />No ---- - - - - --
<br />Rex Johnson
<br />2328 W. 13th Street, Grand Island, Nebraska 68803
<br />20.E LM - SIGN E 8 NSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />n
<br />© Ronal ❑Removal Sept. . 28, 2004 Westlawn Memorial Park
<br />22a. FUNERALHOW14AME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H. ❑Cremalw" ❑D°na°° Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b), AND (c)I Interval between onset and death
<br />I
<br />'k1I(a, ASPHYXIA _ 4- APPROX- 5 min -
<br />■ DUE TO, OR AS A CONSEQUENCE OF - i Interval behiieen onset and death
<br />Ii■ (bl HANGING
<br />e ✓�_ �+• �+^ ^� ^ �.vr.o =ter+ =��= K. Interval between onset and death
<br />I
<br />(c)
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 111 IF FEMALE WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? �� EXAMINER OR CORONER?
<br />It
<br />(Ages 10 -54, Yes No Ves No Yes X No
<br />26a. 26b. DATE OF INJURY /Mb.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW IN.;JRY OCCURRED
<br />❑ Accident ❑ Undetermined 9/24/04 1APPRQX. 110(li SELF INFLICTED HANGING
<br />Suicide ❑ Pending 26e. INJURY AT WORK 26L PLACCE OFNJUU�RY �N hors, farm, street. factory 26g. LOCATIO f1 +ran &TREES eRAF.gNOAve . CITY OR TOWN STATE
<br />❑ Homicide Investigation Yes ❑ No HOME CDi'/ 231 4 N. G- ST-1- 1dilGRAN D ISLAND NE
<br />>s
<br />27b. DATE SIGNED /MO.. Day. Yr.) 27e. TIME OF DEATH
<br />a�
<br />$ M
<br />27d. 7o the best of my knowledge. death occurred at the time, dale and place and due to the
<br />camels) stated.
<br />(Si nature and Tittlej ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DO
<br />1 _ ❑ YES 1 r V NO ❑ UNKNOWN _j/' ❑ YES
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( /D
<br />,f -Sgt. Tim Meguire, Grand IslaLnd Police De[
<br />i J
<br />w=�
<br />a
<br />28a. DATE SIGNED /Md.. Day. Yr.)
<br />°
<br />28b. TIME OF DEATH
<br />eAPPROX. 1 :00am
<br />28c. PRONOUNCED DEAD /MO.. Day, Yr.)
<br />-9/24/04
<br />28d. PRONOUNCED DEAD (Hour)
<br />'x6:23 am
<br />28e. On the basis of examination and,or inv sti
<br />to, 1,fim time, date and place ario t ause s
<br />opinion death occurred at
<br />BEEN CONSIDERED? 30.b WAS CONSENT ANTED?
<br />® NO YES ® NO
<br />= GIS7RAR (MO.. Day. Yr.)
<br />OCT 6 2004
<br />Lots Seven (7) and Nine (9), in Block Twelve (12), in College Addition to ?Jest Lawn, in the
<br />City of Prand Island, Fall County, Nebraska.
<br />
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