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WHEN THIS COPS' CABBIE'S TIE RAISED SEAL OF THE NEBF ASKA HEALTH AND HUMAAG_SERVICES <br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR&E - FI.F -WrTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1ST1C"GCnW_,VNCW= <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - _:- <br />DATE OF ISSUANCE <br />OCT 14 1999 A I 0 STATE REGISTRAR <br />LINCOLN, NEBRASKA __ 200309471 HEALTH AND HUlit/fN 89RWCES, IW <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICRSFINANCE ANOSl1PPORT <br />VITAL STATISTICS " -- <br />CERTIFICATE OF DEATH <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2, SEX <br />3. DATE OF DEATH tMonth. Day. Yearl <br />William Clay Dixon <br />Male <br />October 9, 1999 <br />4. CITY AND STATE OF BIRTH Onol n U S.A.. name country/ <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (MOnih. Day Year) <br />(Yrs.) Sb <br />MOS DAYS <br />Sc. HOURS MINE. <br />Wayne, Kansas <br />89 <br />O <br />I <br />February 1, 1910 <br />7. SOCIAL SECURTIY NUMBER <br />Be . PLACE OF DEATH <br />519 -16 -6054 <br />HOSPITAL: ® Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (enotmufutan, give street and number) <br />St. Francis Medical Center <br />❑ DOA ❑ Other(Specly <br />8c. CITY TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />9a. RESIDENCE - STATE ' 9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (including Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska Hall <br />Grand IS <br />431 E. Nebraska 68801 <br />Yes ® No ❑ <br />10. RACE - (e.g., While. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc) <br />12. � MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /II wile. give maiden name! <br />etc.) (Specify) <br />White <br />(Specify( <br />I American <br />NEVER DIVORCED <br />Shcroeder <br />14a. USUAL OCCUPATION (Give kind of work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary (0 -121 College 11 -4 or 5 <br />of working life, even it retired) <br />Farmer <br />Agriculture <br />12th Grade <br />16. FATHER -NAME FIRST MIDDLE LAST t7 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Dalo NMN Dixon <br />Vesta NMN fencer <br />'8. WA'; DECEAS50 EVER -N U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes. no. or unk.) f,, res. give war and dates of services) <br />No -- - - - - -- <br />Berniece Dixon - Wife <br />I. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) <br />31 E. Nebraska, Grand Island, Nebraska 68801 _ <br />20. �BALMER A T'Un/RE 8 LICENSE NO. I <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. CEMETERY OR CREMATORY, NAME <br />,(J .,� / / <br />j I`. ��,tt_ <br />®Burial ❑Removal <br />Oct. 15, 1999 _ Palisade Cemetery <br />22a. FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston - Sondermann F.H. <br />❑ Cremation ❑ Donat'on <br />Palisade, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal� (b). AND (c)) Interval between onset and death <br />PART <br />k < C� hauS <br />X la) I <br />' �O 0. I <br />DUE TO, OR AS A EO ETE OF Interval between onset and death <br />�p I <br />fir► I y -eGLr <br />(b)�� �v <br />DUE RASA CONSEQUENCE OF: Interval between onset and death <br />I <br />I <br />(c) <br />OT R I NIFIC T CONDITIQNS - Conditions contnbub t aM r t PART <br />PART ' PREGNANCY <br />111 IF FEMALE. WAS THERE A 24. <br />IN THE PAST 3 MONTHS? <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />�� ��� <br />II <br />�lYes <br />y <br />O e (Ages <br />10 -541 Yes No <br />No <br />X Yes No <br />a. <br />26b. DA OF INJURY /MO.. Day. Yrif <br />26c. HOUR OF INJUR <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident F-1 Undetermined <br />M <br />❑Suicide ❑ Pending <br />6e. INJURY AT WORK <br />26f. PULACE %�F. INJURY - At home. farm, street. fa <br />office building, etc. (Specify) 0br1' <br />LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />❑9 <br />Homicide Investigation <br />ygs NO <br />❑ ❑ <br />27a. DATE OF DEATH iti Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />28b TIME OF DEATH <br />M <br />�i' <br />27bb DATE SIGNED fill Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (MO.. Day, Yr.) <br />28d, PRONOUNCED DEAD (Hour/ <br />0 <br />iv✓ I f <br />{/J� <br />1 I� 1 M`� <br />M <br />< <br />u <br />27d. To the best of my k att occur/ d,a d ,date and dace and due to the <br />28s. On the basis d examination and/or investigation, in my opinion death occurred at <br />use(sl stated, <br />a <br />the time, dab and dace and due to the cause(s) stated. <br />IS nature and Tide <br />nature and Tide <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />S CONSENT GRANTED? <br />x ❑ YES NO ❑ UNKNOWN <br />� ❑ YES N.l <br />❑ YES D-(. <br />71r_ <br />31. NAME AND ADDRESS OF CERTIFIER {PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type dr Pdnt) - ^. (11k�� <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yrl <br />OCT 13 1999 <br />