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WHEN THIS COPY CAII THE RAISED SEAL OF THE NEBRASKA HEALTH AND 1
<br />SYSTEM, IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORKaH>8� (
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALS_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA TE
<br />JUN OF (52001
<br />,
<br />200208490 _����s�-
<br />LINCOLN,NEBRASKA HEAL �fJ HUMANS
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN S_ERVI("f.S:
<br />VITAL STATIST( - - - --
<br />CERTIFICATE OFI)EA'1T€1- =. ----
<br />SERVICES
<br />FILE WITH
<br />WHICH IS
<br />01 06006
<br />Jc. iOENI. W /dF FIRST MIDDLE - - -- -LAST - - -
<br />2`>E% /
<br />3 DATE OF DE TH AC, 'va
<br />Steven Ladd Cromer
<br />Male
<br />May 19, 2001
<br />'A Crt'+gNO STATE OF 01NiI• lXrvNn USA nave cOUnNy/
<br />5a. AGE -Lass Oinneay 1
<br />UNDER 1YEAR
<br />UNDER DAY
<br />_
<br />6. DATE 71W BIRTH IMOnOt Uav Rea, -
<br />Kearney, Nebraska
<br />SB MOS ' DAYS
<br />S HOURS MINE
<br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />-
<br />48
<br />OqI
<br />❑LledVoll
<br />August 12 , 1952
<br />_—
<br />Cot-A, SFC✓Rnv NUMBEN
<br />Re rH
<br />505 -62 -4226
<br />HOSPITAL �7 I1 -1-11 EITHER ❑ Nu,mg l,9me
<br />❑ FR Ontuatere ❑ Resiuen[¢
<br />An 1.11ITY Vame ono,• ^s0 /uVOd . g,W,W lanenumM,,
<br />St. Francis Medical Center
<br />❑ GOA ❑ °ne1 / °° °' ^' -- - - --
<br />Oc " v TOVIN OR LOCATION OF DEATH
<br />I q0 INSIDE CITY UNITS
<br />Be eDULLY OF DEATH
<br />Grand Island
<br />Yea IxJ Na ❑
<br />Hall
<br />Iman-aal peladen Onael ale 1 ^a,n
<br />Oa aF3lDENCC SIATE I9n .,nUNTY
<br />9c CITY TOWN OR LOCATION HBO STREET AND NUMBER Pr. W✓rng Z•O(-Adel
<br />9e W9DE C'TY IIMI IS
<br />Nebraska Hall
<br />Cairo 605 Oasis Pl. 68824
<br />Yaa ® NI, ❑
<br />26a ] ATE SIGNED (Ab DaY ✓11
<br />10 FACE do W1me BlacA gmenneAIL
<br />i NCESTRY I,, alun MV,n. Denman, alcl
<br />12 MARRIED ❑WIDOWED
<br />13 NAME OF SPOUSE lX.,A Owe Y.., lama,
<br />mcI'$aalNl
<br />White
<br />rol German
<br />MEHER DIVORCED
<br />Cheryl Oltma_n
<br />tJa USUAL OCCUPATION IGrvebMM mxJare Jwrog moal
<br />Iap HIND OF BUSINESS INDUSTRY
<br />IS EDUCATION S,WTv only nlgnesl g/alAcUT IeJI
<br />I Ame l✓e. even ilrelnWl
<br />•' Dentist
<br />Medical
<br />- -C -
<br />Elamenlary o1 Seconaa+v 10.121 Cone9a. 1 s
<br />+
<br />5 +°
<br />16. FATHER RAN, FIRSI MIDDLE LAST
<br />(]MOTHER FIRST MIDDLE SURNAME
<br />CtIalLners Craver
<br />TM�AI'DEN
<br />UL1% iCl(:hcaan
<br />18 WAS DECEASFD
<br />EVER IN U$. ARMED TORCES3
<br />I9a INFORMANT NAME -
<br />I Oo link(-
<br />,Ii Ves 9rve wa:aM pales el5em[e5,
<br />In T'Ralond Beam nmunatl al
<br />III
<br />V
<br />Cheryl Cromer
<br />n Nh111MANI MAILING ADDRESS (STREET OR R F O NO C" OR TOWN STATE ZIP(
<br />P.O. Box 190 Cairo, NE 68824
<br />20 FM ER- GNATU ICENSEIN
<br />212 METHOD OF DISPOSITION
<br />211, DATE
<br />21a CFMETERYONCNEMAIQHY NAME
<br />'ART CELL�RSGNFICANTCOVDTIONS C9mrl1)ulingbme n6em oul nel Alaiep
<br />II
<br />PA HI nI IF FEMALE WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTM$e
<br />Lk®Bela(-
<br />E] ;1
<br />5/23/01
<br />1 Mt. Pleasant Cemetery
<br />22a F N qL NOME -NAME
<br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />fel Funeral
<br />Home
<br />OqI
<br />❑LledVoll
<br />❑Reaane
<br />U -dl F� �devinnep
<br />Cairo, NE
<br />22p FUNERAL HOME ADDRESS
<br />(STREET OR BE NO CITY OR TORN. STATE.ZIPI
<br />n0 Pcnp °q
<br />411 West 11th
<br />St.
<br />P.O. Box 126
<br />Wood River, NE
<br />68883
<br />20. CAUSE
<br />261 �qq 0 ne meHlarm.
<br />UXpl
<br />(ENTER ONLY ONE CAUSE
<br />PER LINE FOR IA Ill. AND Inll
<br />Iman-aal peladen Onael ale 1 ^a,n
<br />PART
<br />dXce llenINJURYR
<br />9
<br />5"
<br />TRIP TO NCE O
<br />. DR AS
<br />26a ] ATE SIGNED (Ab DaY ✓11
<br />I�demayl debate, onscl aid deem
<br />May 19,2001
<br />C7
<br />W, HASORGAN OR TISSUE DONATION BEEN CONSIDERED' 3D.n WA5 CONSENT GRANTED'
<br />❑ 'F$ NO UNHNOWN ❑ YEG �0 ❑ YES VO
<br />11 UgML AND AODRE550F CERTIFIER IFyYSICIAN, CORONER 5 PHYSICIAN OR COUNTY ATTORNEY( (GRA, Rnnn
<br />Dr Ryan D Crouch DO 80jpha Grand Island, NE 68803
<br />32a 02h DATE FILED BY REGISl.AR (MA Uay D, tire Cn MAY 3 1 2001
<br />South Seventy Feet (S70') of Lot Two (2), Block One (1), Cairo
<br />Mayfield Village 8th Addition, Hall County, Nebraska.
<br />IMelyal boDdAn "YA ann veal^
<br />'ART CELL�RSGNFICANTCOVDTIONS C9mrl1)ulingbme n6em oul nel Alaiep
<br />II
<br />PA HI nI IF FEMALE WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTM$e
<br />2a AuiOP$v
<br />25 waS CABE REFERREp TD MFDICN
<br />E %AMINER OR LORONCH'
<br />J\
<br />�p�'
<br />lam'
<br />5a
<br />Mt INJURY ,M
<br />OqI
<br />DESCRIBE HOW pCCI RREpves
<br />U -dl F� �devinnep
<br />a[
<br />n0 Pcnp °q
<br />CITY OR TOWY 41dF
<br />21a
<br />261 �qq 0 ne meHlarm.
<br />UXpl
<br />peelg Cry
<br />269 LOCATIpNIRV
<br />$iRFFi OR RF0.N0
<br />nmu: nt Inyeellyell
<br />Yea ❑ Np ❑
<br />dXce llenINJURYR
<br />9
<br />a DATE OF DEATH (MU. WY 1
<br />26a ] ATE SIGNED (Ab DaY ✓11
<br />IB0 TIME OF DEATH
<br />May 19,2001
<br />M m
<br />2IL DATE SIGNED (MO. Day Y� l
<br />2]e TIME OF DEATH
<br />N °'
<br />� `
<br />2B[ PRONOUNCED DEAD (AH1 Oay YN
<br />`
<br />280. VHUNUUNCEp pEAO /Hnu•
<br />s 'fl
<br />May
<br />5:35 pm
<br />J
<br />HE,
<br />11
<br />M
<br />r
<br />2]p "1 nasl.1A,Mnowlap9a eea e[urlee ant Net, dale aM q. and eoelo ido
<br />selsl %iaiad 1
<br />(
<br />269. pnlM naaia AT e>tammaadnaM It' lnyesllgallun.
<br />` the ume dale and place and due to Ire, cause (-,
<br />In T'Ralond Beam nmunatl al
<br />III
<br />W, HASORGAN OR TISSUE DONATION BEEN CONSIDERED' 3D.n WA5 CONSENT GRANTED'
<br />❑ 'F$ NO UNHNOWN ❑ YEG �0 ❑ YES VO
<br />11 UgML AND AODRE550F CERTIFIER IFyYSICIAN, CORONER 5 PHYSICIAN OR COUNTY ATTORNEY( (GRA, Rnnn
<br />Dr Ryan D Crouch DO 80jpha Grand Island, NE 68803
<br />32a 02h DATE FILED BY REGISl.AR (MA Uay D, tire Cn MAY 3 1 2001
<br />South Seventy Feet (S70') of Lot Two (2), Block One (1), Cairo
<br />Mayfield Village 8th Addition, Hall County, Nebraska.
<br />
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