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STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />2 1 2 8 8 9 CERTIFICATE OF DEATH
<br />FIRS' MIDDLE LAST 1' SEX 3 DATE
<br />305465
<br />OR
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ;a, Ibl. AND Icll Interval between onset ate oearr
<br />PART
<br />Cardiac Arrest
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Interval between Anse, and neat,
<br />(br Bradycardia months
<br />DUE TO OR AS A CONSEQUENCE OF
<br />Interval between onset anc oewr
<br />IaI
<br />Coronary Artery Disease
<br />I PART OTHER SIGNIFICANT CONDITIONS - ConOmons contributing to Tire oeam but ma related PART III IF FEMALE WAS THERE A 2A AUTppSy years
<br />25 WAS CASE REFERRED TO MEDICAL
<br />L 8 PREGNANCY IN THE PAST 3 MONTHS' EKAMINE I OR CORONER'
<br />(Ages 10 SA Yes No yes Nc Yes F1 Na
<br />TSa 26b DATE OF INJURY /Ma Day Y / 1 26c HOUR OF INJURY 250. DESCRIBE HOW INJURY OCCURRED
<br />r -I
<br />-^ 4c C,O1 J Und2term,ned
<br />M I
<br />i Sutctde ] Peno,ng 2fie INJURY AT WORK :251 PLACE OF INJURY - q1 rnor,le farm street. latlpry 259 LOCATION STREET OR R F D NO CITY OR TOWN STATE
<br />Ce bwWIng etc lSpeMY/
<br />Mort,tctde mvestgattin Yes ❑ No ❑
<br />27a DATE OF DEATH /Ab pay Yr.I 26a DATE SIGNED rMa Day Yr 1 2610 TIME OF DEATH
<br />_< September 22, 2002 =
<br />L 27E DATE SIGN3FD /Ado Day Yn; 27c TIME OF DEATH ( Q I r"t
<br />9 2Bc PRONOUNCED DEAD M, Day 28c PRONOUNCED DEAD lour
<br />�I
<br />11:45
<br />M. M
<br />27C 7 g � M
<br />-2 j�- d t o of my Know edge cu,.ea at r e time dale and dace and due to t o i 2Be On me pasts 01 eKa -31,cn aria or m o5,,gatton .n my oci-on aeam occurred at
<br />causes, swell 1 A .: a the lime. date and pace aria oue to One causes, stated
<br />nature and Tteel ► t ► ! e aria TItIeI
<br />29 DID TOBACCO USE CCNTRIBU THE DEATHn 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.D WAS CONSENT GRANTED
<br />I ❑ YES ❑ NO ® UNKNOWN YES � NO ❑ YES ❑ NC
<br />AME AND ADDRESS OF CERTIFIER PH SI IAN ')RONE PHYSICUIN OR RUNTY A- TORNEY YOe or Prml
<br />Ginger Massey,MP I;d�cal Center, 4101 Woolworth Ave., Omaha,NE 68105
<br />32a PEGISTRAR A'
<br />1 • �-.. r
<br />32E DATE FLED By RE r.TPAP Mo Dat
<br />� 1
<br />This cerrilies -this docVnenr to be a true copy of an original record on file with vital
<br />Statistics,-.Douvlas C*nty -H "lth Department, Omaha, Nebraska, Certified copies must have
<br />a raised se 1 -Lin the ea tPthe left. Reproductions of this green certificate are not
<br />legal copies,-1 P ,2� 5 2002
<br />Date issued:_ Registrar:
<br />The Northerly Forty -four (44 feet of the Southerly Fi_ghty -eight (88) eet of Lots Nine (9)
<br />and Ten (10), in Block Twenty -one (21), in Schimmer's Addition to the Citv of Prand ?sland,
<br />Hall County, Nebraska.
<br />DF DEATH - ,Munn, uav rear
<br />Sanford
<br />E Glover
<br />a _rte AND STATE OF BIRTH a torn L S A name count,,
<br />5a AGE - mast Btrmdav UNDER' YEAR UNDEP ' DAV 6 ATE OF BIRCH MOnm Da. year'
<br />Red Cloud Nebraska
<br />IVrs 50 MOS DAYS 5c HOURS MINS
<br />87
<br />SECURP NUMBER
<br />Ba 'LACE OF DEATH ul-Y 11, 1915
<br />508 18 5854
<br />HOSPITAL ,noa,em OTHE, ❑ N.,s -,-U
<br />BC = ;ILiT• Ndme /Ina srt,T -9", sr/ee'drC
<br />ttw ❑dl EP 3A..uem
<br />VA Medical Medical Center
<br />❑ DoA ❑ Dine Sa
<br />8c - '• TOWN OR LOCAT -Oh DF DEATH
<br />8c INSIDE CITY,WITS I Be COUNT, OF DEATH
<br />Omaha
<br />'IG t No ❑ Douglas
<br />9. PESIDENCE - STATE 90 COUNTY
<br />Nebraska Hall
<br />19c CITY TOWN OR LOCATION 19d STREET AND NUMBER dnau0r rig Zrr Cane: � 9e INSIDE CITY LIMITS
<br />Grand Island 11606
<br />N Cleburn 68801 Yes No ❑
<br />RACE e9 Wnae Slac Arne ca enda t ANCESTRY
<br />eq talar
<br />etc Sceoty. 'SoeeW
<br />Me ca Gerr,a etc 12 ® MARRIED ❑WIDOWED t3 NAME OF SPOUSE dr wde orve marcenname
<br />I
<br />1
<br />White En
<br />llsh DIVORCED
<br />MARRR Evelyn Wldhalm
<br />'Ac _SJAL OCCUPATION G,ve krnOd war. dprrp during most
<br />o/ —1—C de ever d rer,rea.
<br />14b KING OF BUSINESS INDUSTRY 'S EDUCATION '$cec,ly onn n. guest grace completed,
<br />Salesman
<br />Elementary or $ecomaN 6 2) CN Liquor n 8
<br />15 FATHER - NAME FIRST MIDDLE
<br />LAST X17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Andrew Martin
<br />!_ :•'•_ DECEASED EVE" '�. '..' cngCES'
<br />Glover Julia Alice Had pod
<br />S Apucp
<br />I 'Yes c o, urw n yes 9tve war am adles of se -ces,
<br />.oa tNCORMANT Nn,ME
<br />yes !WWII /8 -7- 42/8 -23 -43
<br />Evelyn Glover
<br />1910 INFORMANT MAILING ADDRESS STREET OR R F D NO CITY OR TOWN STATE. ZIP(
<br />1606 N. Cleburn
<br />Grand Island NE 68801
<br />- 20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21a METHOD OF DISPOSITION i 2110 DATE 21 CE RY OR E Rv
<br />$ea"
<br />Not Embalmed
<br />try -for ann Dworak
<br />/�(�
<br />❑Burial ❑RemoYal (Sept. 24, 2W2 i R Cut CrPlil'lrnry
<br />210 CEMETERY OR „REMATORV LOCATION CITY OR TOWN STATE
<br />® C---. ❑ D",
<br />22, FUNERAL 1101WE -NAME
<br />�Opfel- Butler- Geddes
<br />OR
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ;a, Ibl. AND Icll Interval between onset ate oearr
<br />PART
<br />Cardiac Arrest
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Interval between Anse, and neat,
<br />(br Bradycardia months
<br />DUE TO OR AS A CONSEQUENCE OF
<br />Interval between onset anc oewr
<br />IaI
<br />Coronary Artery Disease
<br />I PART OTHER SIGNIFICANT CONDITIONS - ConOmons contributing to Tire oeam but ma related PART III IF FEMALE WAS THERE A 2A AUTppSy years
<br />25 WAS CASE REFERRED TO MEDICAL
<br />L 8 PREGNANCY IN THE PAST 3 MONTHS' EKAMINE I OR CORONER'
<br />(Ages 10 SA Yes No yes Nc Yes F1 Na
<br />TSa 26b DATE OF INJURY /Ma Day Y / 1 26c HOUR OF INJURY 250. DESCRIBE HOW INJURY OCCURRED
<br />r -I
<br />-^ 4c C,O1 J Und2term,ned
<br />M I
<br />i Sutctde ] Peno,ng 2fie INJURY AT WORK :251 PLACE OF INJURY - q1 rnor,le farm street. latlpry 259 LOCATION STREET OR R F D NO CITY OR TOWN STATE
<br />Ce bwWIng etc lSpeMY/
<br />Mort,tctde mvestgattin Yes ❑ No ❑
<br />27a DATE OF DEATH /Ab pay Yr.I 26a DATE SIGNED rMa Day Yr 1 2610 TIME OF DEATH
<br />_< September 22, 2002 =
<br />L 27E DATE SIGN3FD /Ado Day Yn; 27c TIME OF DEATH ( Q I r"t
<br />9 2Bc PRONOUNCED DEAD M, Day 28c PRONOUNCED DEAD lour
<br />�I
<br />11:45
<br />M. M
<br />27C 7 g � M
<br />-2 j�- d t o of my Know edge cu,.ea at r e time dale and dace and due to t o i 2Be On me pasts 01 eKa -31,cn aria or m o5,,gatton .n my oci-on aeam occurred at
<br />causes, swell 1 A .: a the lime. date and pace aria oue to One causes, stated
<br />nature and Tteel ► t ► ! e aria TItIeI
<br />29 DID TOBACCO USE CCNTRIBU THE DEATHn 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.D WAS CONSENT GRANTED
<br />I ❑ YES ❑ NO ® UNKNOWN YES � NO ❑ YES ❑ NC
<br />AME AND ADDRESS OF CERTIFIER PH SI IAN ')RONE PHYSICUIN OR RUNTY A- TORNEY YOe or Prml
<br />Ginger Massey,MP I;d�cal Center, 4101 Woolworth Ave., Omaha,NE 68105
<br />32a PEGISTRAR A'
<br />1 • �-.. r
<br />32E DATE FLED By RE r.TPAP Mo Dat
<br />� 1
<br />This cerrilies -this docVnenr to be a true copy of an original record on file with vital
<br />Statistics,-.Douvlas C*nty -H "lth Department, Omaha, Nebraska, Certified copies must have
<br />a raised se 1 -Lin the ea tPthe left. Reproductions of this green certificate are not
<br />legal copies,-1 P ,2� 5 2002
<br />Date issued:_ Registrar:
<br />The Northerly Forty -four (44 feet of the Southerly Fi_ghty -eight (88) eet of Lots Nine (9)
<br />and Ten (10), in Block Twenty -one (21), in Schimmer's Addition to the Citv of Prand ?sland,
<br />Hall County, Nebraska.
<br />
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