200207797 - Laserfiche WebLink

Browse

A. 1197 z Z w w w w w 0 w Q Z M Us C O ,r J O 0 dj E M TO d A O E R N T L n d N U. STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 2011 9 n 7 7 a 7 I DECEDENT NAME FIRST MIDDLE LAST J SEA ] DATE OF DEATH /AXnln Dnv YXXrI Everett Elias Randall Male Junet 15. 2002_- . CIl V AN051giE OF BIRTH /X/pfb GSA. rwnX GC4rlry/ SA LSd BlnMny UNDER I YEAH UNDER I DAY S. DATE OF BIRTH rF4rMi Ony Y.nr, _- (11,1 N MOS PAYS Sc HOURS ' MINS insworth, Nebraska 87 August 4. 19 15__.. QIALSECURTIYNUMBER OR PLACE OF DEATH - 518 -09 -5175 HOSPITAL ❑ ill.M OTHER ® NwfmPH _ ACILITY - OR. /XnAR.AMkn pyflrM/wrq nunrMFl ❑ FRO"RAIROM ❑ R[TMre 1VLaLIDJl Nebraska Veterans Home ❑ LOA ❑ o»r /Vwm _ CITY ipYN OR IOCgTgN OF OFATH p1 INSIDE CITY LIMIL9 Aa COUNTY OF DEATH Island Nebraska Y.,U ❑ H A RF.51pENCE3TAif SD COUNTY Or CITY. TOWN OR LOCATION W STREET AND NUMBER ifi[AEiN�'.A!slYl W INSIDE CIT\ P \Vy Nebraska Hall Gran Island 23Uu W. Capital 6880 X. JNA ❑ 10 MCE InOWNM. 01n[4 Amnr¢an WFan II ANfFSIRV M R 1101W. AMnpn. MmMn, FUT IP DFT MADRIEO F'"T WIIgWEO ONA.1(W APOI IOF In win P.r. nivi A.m, rEEE.J�� LI Ni, 1ISWAVI ISPRONI NEVER DIVORCED White American Zola Gathel Heese IRS USUALOLCUPATION /Give AMQd rorAdAN Annpnxnl IaN KIND OFRUSNESSINDUStRY IS EDUCATION ISM[Ay pW ngMMpXM [wnpMNO) d wndvp x4 sMn /nFmll :Maintenance Supervisor De artment Of Roads F IwY m SPCPMe�y IP 191 Cmlpr n 1" l�th Grade rX FAIHER NAME FR51 MIDDLE LAST ) MOTHER FIRSt MIDDLE MAIDEN SURNAME Earl Randall E Stufft , IA WAS DECEASED EVER IN US. ARMED FORCES? 1% INFORMANT NAME WAR - w PI1r I IN b. 0. •N and 6. d faOni Yes Navy WWII 1940 -1946 Zola Randall I 1. nn'RMANT MAILNG ADDRESS (STREET ORRF.0 NO. CITY OR TOW N. STATE. ZIP) 2212 North Sheridan Grand Islands Nebraska PO FMRAIMER- $IONSIUREEl6ENSE NO 9M METHODOFOSPOSITION _ 71h DATE 21C CFMFIERYORCRF MN OnY NAME Not Embalmed ❑a1 „.I ❑Rn--P June 15, 2002 Westl_awn Crematory 22a FONERALHOME� NAME 21A CEMETERY ORCREMATORY LOCATION CITYORTOWN S1AIF Livin ston- Sondermann F.H. ®`'” "� ❑ ° "" Grand Island, Nebraska 2A FUNERAL HOME ADDRESS STREET OR R.FD NO CITY OR TOWN STATE.21P 601 North Webb Road, Grand Island, Nebraska 68803 -4050 __ "MEDIATE CAUSE (ENTER ONLY ONE CAUSE PFA LINE FOR dI IKL AND RII Man d. RE I /�[ ) /� �L � / �(YL 2 �/ /� (' (' I.I �_.m_{�1V"Iz P ` P. O� O ___ DUE TO. OR AS A CONSEWENCE OF RR Nxwap enfw R++ +•n [PA A I ml IXIE TO On A$ACONSEQUENCE OF I ldnvnllgbeen pna[lnro mw• - I ([I PART OTHER SIGNFICANT CONDITIONS CwMXrom [wMiEUXrg 10 X <peaT lM nU rdnle� pggi IX IF FEMALE. WA$THEREA 2a AUTOPSY 25 WAS USE REFEORED IO MFMR 11 PREGNANCY IN THE PAST O MONTH$F EXAMINERDRCdIp1FS' IASPs 10 -5Ma MO PATE OF INJURY Al .Dry Yq Mc. HOUR OF NJURY Mtl. DESCRIBE HOW INJURY OCCURRED AcoEPM �rl WMaM'nX'IM M ❑ Snnc4e u PeMlnp M. NJURY AT WORK M LAACEZ.IN URY rp" larm. nlrad letbry 6g LOGATgN $IREET OR RFO Np Oq ipNN SlaiF o1X LvXE SGT[ ❑ Ilrcnega InOHMalmn V., ❑ Np ❑ I 2Tf DATEOi TAM�N, YA MA DATE SHINED ,Ab. Done Yrl MO TIME OF DEATH 0&- ( 19- -I E EIS M 2M DATE SQNEDD /AM DAY 11t 22c TIME OF DEATH t Mc PRONOUNCEODEAD IRA, Yrl Mtl PRONOUNCFODEAD OAR, /ten t7e IM y rrlew4 nMP[CMeUYIM XrM, Ctl aM Mee AM meMM a Se O1M n M nye a [ym MY IXCM�. n cIo ey el sMl HNeabOm. i. lma. OPAR q dece POOL On b M RRARRNI fARML . 110' IS Nw. Ma TM )770 nMYMfM TM. M DIOTOBAGCOUSECONI TETGTHFDEATNf ,pa HAS ORGAN OR TISSUE DONATION BEEN CONSIMREDi SO h WAS CCNSEN I GRANTED' ❑ YES NO ❑ UNKNOWN ❑ YES w NO jALy. ❑ YES (Ote NO �—` 31 NAME ANp AD0RE550 GERT6IER PNV$IGAN.CORGNERS PHY9CMN OR CGIINTYATTORNEYI Phan R/Ml Sheridan Anderson M.D. Nebraska Veterans Home Gyand Island.Neb raska 68803 32. REGISTRAR _ OM DATE FILED BY REGISTRAR MM OnY VI/ FOR VITAL STATISTICS USE ONLY Place.......................A ..................... ... ........ B ..................... NSC .......................... _ ...................................................... :.. Work...................................................... ............................... Reject 1� Prinl.P wm fM Ina Pn.....1.a P.PP.11111 I hereby certify this to be a true and correct copy of the original filed Vith the State of Nebraska by Signed in my of�1e:;vx��n Notary Public ..............TMV ........................... ................ Census Tract No. ffM1'COA'flIXM11S'SI0NEXPIRES