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WHaj THIS COPY CARIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA#SER1 /ICES <br />SYSTEM, IT CERTE/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOM -ILO N.FILEi49TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA77STICS SECTION, °1R!HICHJS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />t 'E* N 690PEit= <br />AUG 12 2002 AS81C STATE*,/iEGdii?i Wz <br />LINCOLN, NEBRASKA HEALTH AND HdWAN`4Eft7ES -SYSTEA <br />200305393 = --- <br />STATE Of NEMIUL KA — WARTU M Of HEALTH <br />GUMM OF A 'MOF 1 93-03241 <br />I. DECEDENT - Kma FIRST MIDDLE LAST <br />Is" <br />a. DATE OF DEATH fhbn^ Ow YAM) <br />Michael Patrick Hannon <br />Male <br />March 6 199 <br />p AND STATE OF WITH 01AWU U" MWWaWIL'T) <br />11t AGE • UW OW4@V I <br />UUMa I YE <br />DATE OF SIIITN w.. OAC YAWA <br />Sa IrIS <br />IWaI <br />S11 MDS OAYi <br />Wood River, Nebraska <br />89 <br />Jul 1 <br />7. SOCIAL SECUFM NUNIEN Ila <br />PLACE OF DEATH HOSWTAL O M PNMM O ERUOlAm"m 0 DOA <br />507 -48 -2518 <br />P1w— SNo- 0 Raaa1— ❑Dow Isp-ow <br />S0. FACILITY - Mom 1►wpf IIIIAA71l SAr OMR ane n1wle'a/ <br />11C. CRY. TOWN OR LOCATION OF DEATH <br />11Q INSIDE CRY 1.I14179 IS. COUNTY OF DEATH <br />(3Pbe/Y YN a AIg1 <br />Wedgwood Manor <br />Grand Island <br />es Hall <br />SA RElDdCE -STATE <br />ft COUIRY <br />fle. CRY. TOWN OR LOCATION <br />11IL STREET AND NUMBER I&CAK6II Zb Co." <br />M INSIDE CRY LIMITS <br />12017 <br />(Smog Yee a All <br />Nebraska <br />Hall <br />Grand Island <br />W 11th Av. <br />yes <br />10 RACE - WS. WMAIL auk AAaIkM MIIWL <br />ANCES I.Y (AaA mAM MaAeWA Gmawl Aal I 12 MAFMDl1EVEA MARRIED. <br />11 NAME OF SPOUSE 9 .11r. IA'a MakNw, Aaam1 <br />abl op o w <br />111. <br />l iY1 WIDOWED. DIVORCED (8PIey( <br />White <br />Irish C� Married <br />Elaine <br />14& USUAL OCCUPATION A** fAMOR. W* MM Aaap Amt/ <br />Lab KIND OF BUSINESS INDUSTRY <br />El wr w m gm dwy p• 121 Colbla 11-a m 5•1 <br />d aaslla o MIA ~ t - Ll <br />Q)\\ <br />Farmer ��� <br />Agriculture <br />1• FATHER - NAME FIRST WOOLE LAST <br />17. MOTHER. MAIDEN NAME FIRST MICOIE LAST <br />Michael P. Hannon <br />1 <br />_ <br />IS. WAS DECEASED EVER W U.S. ARMED FORCES? 1I. INFORMANT - NAME - MASUN0 ADDRESS 1ST OR FLF 0. NO- CRY OA TOWN. STATE ZIP) <br />IRK nb. a aIJR h Yaa. SM oar an0 eaw b aarvkaa) <br />no Elaine Hannon, Box <br />Wood River. Nehraska 68893 <br />"a BURIAL CmmftwkPm wNA <br />DorWbn <br />200. DATE <br />-4 <br />20e. CEMETERY OR CREMATORY - NAME 200. <br />LOCATION ". TY OR TOWN STATE <br />Burial <br />March 9 1993 <br />St Mary's <br />Z1. EMBALMER - SIGNATURE S NO <br />22. fUNERAL NOME -NAME AND ADORERS ISTREET OR RF.O. NO.. CRY OR TOWN, STATE Z1% <br />12-115 <br />u <br />A fel Funeral Home Wood River Nebraska <br />ART CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 14 p* AND leg ""411 bWwan awl Owl doom eaa <br />' JAI STtid J Q.y1 K /N�Lii <br />DUE TO. OR AS A CONSEQUENCE OF: aaarval OIIaIan aIIW NYTO —O��w <br />DUE TU. OR AS A CONSIOUBiCE OF: I MKWr.I babaan anew Wm doom <br />1 <br />P OTHER SIGNIFICANT OONORIONS - Cw~4 eort/YYq b aaM boa nM MIIIW <br />PART M IF FEMALE WAS THERE A 2a, <br />PREGNANCY IN THE PAST S MONTHS? <br />AUTOPSY <br />2S. WAR CASE REFERRED TO MEDICAL. <br />11 <br />C>A0I <br />(3PaeA' Y a MN <br />EXAMINER <br />(3awNry r RONEm <br />W' <br />Y« O NO O <br />/0t <br />211a ACCIDENT. SUICIDE, HOM1ICIDL MILDER. <br />DATE OF INJURY ob.-Ow. ") <br />HOUR OF PLJURY <br />2NM DESCRIBE HOW INJURY OCCURRED <br />IUD, <br />OR WENDING INVESTIGATION Mom" <br />126L <br />Zia KAM AT WORK <br />2K PLACE OF KAMY - M ft.W MM W*K henry, <br />iSS LOCATION STREET OR RFO NO CRY OR TOWN STATE <br />131Paef/y Yof a AW <br />olSab bm*%am imNKr1Y <br />27► DATE OF DEATH Coy. Y j <br />24 DATE SIGNED (M?_ DIy. Mil <br />2110 TIME OF DEATH <br />3 -6-93 <br />s <br />j <br />CC <br />—ft DATE SIGNED AML OaA WA <br />270. T ME OF DEATH <br />2ft PR DNOumcED DEAD rub. Dry. Y,; <br />tie PRONOUNCED DEW f ovl <br />d <br />9 — <4 - -1 <br />10:50 <br />o <br />77e. To 111a Dow of my' n III II I�ia ._o TP <br />2" On M balw of wan wM awta mvembp o^. m ^M opmmm a,1 oaunao a <br />s <br />F <br />Cauaa(N maw �/ <br />b <br />bN bM, QaM WIe Dlaca am eaa m YN eaaaalN It~ <br />one T- 0, <br />aft TM <br />2N, DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />20a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? IOb. WAS CONSENT CRANED? <br />1 <br />O YES ONO <br />O YES -14 O YES Uq <br />.. +.awe _.w+ wuaw.caa u. a,c... vcn Irniaw...R 1nw.uwcn a ... • a.w. �...,wn � . _. � Vrr.c.I I.n. u.....a <br />4 e <br />