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I. DECEDENT -NAME FIRST MIDDLE LAST <br />;10 <br />r) <br />t <br />54. AGE- Let OkfidW I <br />WNW IMCOPYCARFM "EkAM0 SFA 0FTfl9XF&U8K4MrALTH <br />Y <br />'ROURS� <br />XMW ff 4F0WW IMMM W PE A TAVE COPY OF THE <br />_W <br />5b. MOS. <br />M <br />x <br />> <br />Decentr 10, 1919 <br />APR 2 5 ZOR �=I. <br />ft. PLACE OF DEATH <br />No — <br />505-12-1182 <br />L%WLM AWMXCA, 7 <br />n <br />M <br />CA <br />1z , <br />A 0, 7 19 <br />CERnMATE OF Dt <br />. I <br />April 18, 2002 <br />C <br />r) <br />= <br />Yes <br />M. DATE SIGNED (Ma. Day. Yrj <br />April 19, 2002 <br />ga RESIDENCE •STATE <br />9b. COUNTY <br />z <br />91 STREET AND NUMBER fkio"W '*c <br />_` <br />INSIDEE CITY LIMITS. <br />Nebraska <br />c <br />ca <br />n <br />= <br />10. RACE - (e.g.. While. Black. American Wen. <br />11. ANCESTRY jo4 NaMix Mekew. ewmw. *1 <br />92. MARRIED <br />13.NAMEOFSPOUSE I190W.g0wmadwflaml <br />ry <br />c5 ) V <br />DWORCED <br />Alice A._johnsoiR+(d#c.) <br />14a, USUALOCCUPATION (Give kkdcf wtv* d"&#MmW <br />14b, KIND OF BUSINESS INDUSTRY <br />ATION (Specify oray grade Ixmpiebdl <br />7 <br />Truck-Driver <br />Over The Road <br />16. FATHER NAME FIRST MIDDLE LAST <br />MOTHER AWT MIDDLE MAIDEN SURNAME <br />Charles Johnson <br />Nelson <br />18. WAS DECEASED EVER IN U.S. ARMED FORMS! <br />' ga INFORMAKr-NAME <br />3; um 0#_42"e`jZd8Tj-"=L45 <br />Janice Jaku I bovski <br />19b. INFORMANT MAILING ADDRESS (STREET OR RF.D. NO.. C&TY,Oft TCIIIIIN. STATE. ZIP) <br />1203 WestAth St. Grand Island Nebras a 68801 <br />WMTURE & LICENSE NO. <br />21&WMWOFDW4W0N <br />210. DATE tic <br />CEMETgFYOROASMATORY NAME <br />April 22, 2002- flie <br />st lawn -Memorial Park <br />FUN - NAME <br />21d. CEMETERY ORCI DCKTION CITY OR TOWN STATE <br />n <br />Grand Island NE <br />10 tL, <br />= M <br />rM <br />—0 <br />3> OD <br />M <br />=3 <br />r— M <br />"or <br />I. DECEDENT -NAME FIRST MIDDLE LAST <br />Hemian W. Johnson <br />i1 18, 2002 <br />t <br />54. AGE- Let OkfidW I <br />WNW IMCOPYCARFM "EkAM0 SFA 0FTfl9XF&U8K4MrALTH <br />Y <br />'ROURS� <br />XMW ff 4F0WW IMMM W PE A TAVE COPY OF THE <br />_W <br />5b. MOS. <br />W W AWN000 Wft WrAW STA <br />T#* LE&AL DEPOSTORY FOX WAL AEOM& <br />Grand Island, Nebraskat <br />'7*TF 0"'"Nw '!�7!-20020 11 <br />Decentr 10, 1919 <br />APR 2 5 ZOR �=I. <br />ft. PLACE OF DEATH <br />No — <br />505-12-1182 <br />L%WLM AWMXCA, 7 <br />STATE OF NEBRASU- DEPARTSUNT OF HEALTH AWWD <br />VITAL <br />Sb. FACILITY - Name tff nof rafthwa ghv aelNaNnernW <br />1z , <br />A 0, 7 19 <br />CERnMATE OF Dt <br />. I <br />I. DECEDENT -NAME FIRST MIDDLE LAST <br />Hemian W. Johnson <br />i1 18, 2002 <br />j4. CRY ANOsTATEoFBIRTH <br />54. AGE- Let OkfidW I <br />UNDER <br />Y <br />'ROURS� <br />S. DATE OF BIRTH JAIWA Day YW <br />5b. MOS. <br />MW <br />Grand Island, Nebraskat <br />82 <br />Decentr 10, 1919 <br />7. SOCIAL SECUFfnY NUMBER <br />ft. PLACE OF DEATH <br />No — <br />505-12-1182 <br />ER OutpWort Residence <br />Sb. FACILITY - Name tff nof rafthwa ghv aelNaNnernW <br />.Grand Island VeteransHame <br />❑ CQA <br />4- <br />rem 4 <br />April 18, 2002 <br />0 No 01 <br />Hall County <br />Yes <br />M. DATE SIGNED (Ma. Day. Yrj <br />April 19, 2002 <br />ga RESIDENCE •STATE <br />9b. COUNTY <br />90. QTY, TOWN OR LOCATION <br />91 STREET AND NUMBER fkio"W '*c <br />_` <br />INSIDEE CITY LIMITS. <br />Nebraska <br />Hall <br />Grand Island <br />709 S. Pine St.,6.88 0=1 <br />Yeen No El <br />10. RACE - (e.g.. While. Black. American Wen. <br />11. ANCESTRY jo4 NaMix Mekew. ewmw. *1 <br />92. MARRIED <br />13.NAMEOFSPOUSE I190W.g0wmadwflaml <br />elc.11specayf White <br />(s4l I Danish/Swedish <br />DWORCED <br />Alice A._johnsoiR+(d#c.) <br />14a, USUALOCCUPATION (Give kkdcf wtv* d"&#MmW <br />14b, KIND OF BUSINESS INDUSTRY <br />ATION (Specify oray grade Ixmpiebdl <br />7 <br />Truck-Driver <br />Over The Road <br />16. FATHER NAME FIRST MIDDLE LAST <br />MOTHER AWT MIDDLE MAIDEN SURNAME <br />Charles Johnson <br />Nelson <br />18. WAS DECEASED EVER IN U.S. ARMED FORMS! <br />' ga INFORMAKr-NAME <br />3; um 0#_42"e`jZd8Tj-"=L45 <br />Janice Jaku I bovski <br />19b. INFORMANT MAILING ADDRESS (STREET OR RF.D. NO.. C&TY,Oft TCIIIIIN. STATE. ZIP) <br />1203 WestAth St. Grand Island Nebras a 68801 <br />WMTURE & LICENSE NO. <br />21&WMWOFDW4W0N <br />210. DATE tic <br />CEMETgFYOROASMATORY NAME <br />April 22, 2002- flie <br />st lawn -Memorial Park <br />FUN - NAME <br />21d. CEMETERY ORCI DCKTION CITY OR TOWN STATE <br />Curran Funeral Chapel <br />Grand Island NE <br />M. FUNERAL HOME ADDRESS (STREET OR RF.D. NO..CrTYORI—,­fE, —j 1, <br />3005 S. Locust St. Grand Island, NE 68801 <br />Ime.-al bet~ <br />21 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. jbi. AND (CH afW deatt, <br />PART • <br />I Acute Respiratory Failure 12-4 �hpiyr <br />(a) <br />DUE: TO. OR A&A CONSEOLVNCE <br />Z <br />wo W­ <br />pa <br />MR S�*�N PART <br />PAFITI��WyfiiSQ3NDbK)NIjeCWW%Cofl!l�� nqVed <br />a e • S PREGNANCY <br />CHF. <br />III IF FEMAILE W A <br />ASTWORE, , <br />IN THE A <br />(Agee 10-541 Yee t10 <br />urea No <br />kSE REFERRED TO MEDICAL <br />iEA OR CORONER? <br />Y« El No <br />26a <br />Wb. DATE OF "RY /Mo. Day. Yr.) <br />28-- HOUR OF INJURY <br />Accidert ❑ Undetermined <br />Sticift Ej Pending <br />We WWAY AT WORK <br />261 AgK2411J.RY -AM. farm. <br />STREET OR R.F.D. NO. CftYOATOWN STATE <br />Homicide Investigation <br />yes ED 1:11 <br />27e. DATE OF DEATH (Me.. Day. Yr) <br />na DAX- sxmv (W. Day. yo <br />`2WA TIME OF DEATH <br />April 18, 2002 <br />M <br />M. DATE SIGNED (Ma. Day. Yrj <br />April 19, 2002 <br />27c. TIME OF DEATH <br />7A3O P M <br />2111c, PRONOUNCED DEAD filla. Day, Yr.1 <br />M <br />27d To dw base of nW knowledge, death occurred at Ow *M. drA sed4ioq W4 due 10 Ove <br />cuts" .81 ~. <br />2"' 00 OWbWs of examination aridoor OW OpirliDa deaf OWURW st <br />0, � #*W1% dide MW pliic. W4 due 10 to SWpd <br />0, <br />(SOWNIAND Will TAM 0 10`7 A <br />mid Tiee) P. <br />29. DID TOBACCO <br />USE CONTRIBUTE TO THE DEATH? Me+ Mis ORGAN OR Tk--%* D <br />30.b WA$0WW_0A_MTED7 <br />ElYES Ej NO UNKNOWN YES <br />YES NO <br />M. A. Tim1pkim, M.D., Island Veterans jf�� `-'Grand Is �.,IE 68803 <br />GrV <br />32a. REGISTRAR DATE F116" fY FISGISTRAR (ft - Day YA/ <br />APR 2 4 2002 <br />