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I
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYST7=M, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />8/1/2003 200502552 ANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />�
<br />VITAL STATISTICS 08509
<br />CERTIFICATE OF DEATH v .J
<br />70FCEDENT . NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH 30,11n. Jay. Year)
<br />Albert Joseph Lawrence Jr. Male July 25, 2003
<br />�SACIAL STATE OF BIRTH /u not ul u.SA., name cdunfry) Sa. AGE -Last Binnday UNDER t YEAR UNDER 1 DAY
<br />6. DATE OF BIRTH !Motel. Oay. Year!
<br />inson, Nebraska (Yrs.) 70 5b. MOS. I DAYS 5c. HOURS MINS
<br />August 17, 1932
<br />ECURTIY NUMBER Ba, PLACE OF DEATH
<br />508-32-3322 HOSP_ ITAL: (.Assam OTHER ❑ Nursing Home
<br />31b. FACILI I Y - Name fit no$ mslilihOn. give srreef and number) ❑ ER Outpatient ❑ Residence
<br />St. Francis Medical Center ❑ DOA ❑ Other iSpecdvr
<br />dc. CITY, rOWN OR LOCATION OF tlEAYH
<br />Grand Island
<br />9a. RESIDENCE - STATE 9h, COUNTY
<br />Nebraska I Hall
<br />10. RACE - (e.g., While. Black. AmenCan Indian, I 11. ANCESTRY la.g.. llallan. I
<br />atc.) ISoecllyl fSpeclly)
<br />Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Yes 0-11
<br />CITY. TOWN OR LOCATION
<br />Grand Island
<br />an. German, alc1 1 12, f-,71 N
<br />White American NEVER
<br />MAR
<br />14a, USUAL OCCUPATION !Give kindo/ work done durmg mosr 14b KIND OF BUSINESS INDUSTRY
<br />or workmg fire, even it reliredl
<br />Industrial Engineer Manufacturing Plant
<br />16. FATHER -NAME FIRST MIDDLE LAST 117 MOTHER
<br />90. STREET AND NUMBEn flnc,u:vnJ yip i.',wnl de INSIDE CITY r IMITS
<br />2205 Rue De College6$803 Yes © No ❑
<br />❑ WIDOWED 13. NAME OF SPOUSE fk -de, give maiden name) DIVORCED Shirley Larson
<br />15. EDUCATION ISpe - only nignest gentle "mpleteol
<br />Efemenlaryfrlecondary 10.12) College 11.4 or 5 -I
<br />Albert Joseph Lawrence Sri Caroline
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? IBe. INFORMANT - NAME
<br />(Yes. no or nd unk.) III yes. give war a dates of services)
<br />Yes 3/53 --2/55 Shirley Lawrence
<br />130. INFORMANT MAILING AODRE55 (STREET OR R.P.D. NO., CITY OR TOWN. STATE, ZIP)
<br />2205 Rue De College Grand Island, Nebraska 68803
<br />20. ALMER - SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE
<br />R. CL..tiI(3 [NBurial []Remove, July 28, 2003
<br />22a. FUNERAL HOME - NAME 21 d. CEMETERY OR CREMATOR)
<br />Livingston- Sondermann F.H. ❑c' °ma"° ❑°one°" Grand Island
<br />22b. FUNERAL HOME A0 0RESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 North Webb Road Grand Island, Nebraska 68803
<br />?3. PART � IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al, lot, AND lei)
<br />( �A // �� / w � �
<br />fat /�5�/l' CSI /.rj�f/
<br />OUE TO, OR AS A CONSEQUENCE - (IF:
<br />EQ OF
<br />UENCE
<br />IV
<br />OUe TO, OR Ab A CONSEQUENCE OF:
<br />MIUULE MAIDEN
<br />Bausch
<br />21c. CEMETERYORCREMATORY NAME
<br />Westlawn Memorial Park Cem.
<br />;ATION CITY UR TOWN STATE
<br />Nebraska
<br />Icl
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY
<br />II PREGNANCY IN THE PAST 3 MONTHS?
<br />(Ages 10.54) Yes No Yes Np
<br />26a. 260. DATE OF INJURY iMa. Clay, Yr.) 126c. HOUR OF INJURY I 26d. DESCRIBE HOW IN.,JRY OCCURRED
<br />Accident Undetermined M
<br />Suicide Pending 26a. INJURY AT WORK 20f. PLACE OF INJURY • t home, !arm. street. factory 26g. LOCATION STREET OR R.F.O. NO.
<br />mlc
<br />❑ rN/
<br />Haide Invasngau 11 nn Yes No ❑ ce building, W. I
<br />27a. DATE OF DEATH iMa. pay. Yr.) 28a. DATE SIGNED /Me.. Day, Yr)
<br />27b. DATE SIGNED /Ma. Day, Yr.)
<br />2 Zd 10 ",, e best al my kno e. e.
<br />edg
<br />causestaled.
<br />ISi nawre and Tittei ►
<br />27c. TIME OF DEATH
<br />3 1 X -F" M
<br />occurred al the lime, e a d place and due to the
<br />c 1? i1
<br />22 r 28C. PRONOUNCED DEAD /MV., Day, Yr)
<br />Interval between onset and death
<br />Interval between onset and deem
<br />I
<br />S >,
<br />I Interval between onset and death
<br />I
<br />I
<br />25. WAS CASE REFERRED YO MEDICAL
<br />XEXAMINER OR CORONER'
<br />Yes No
<br />CITY OR TOWN STATE
<br />28b. TIME OF DEATH
<br />M
<br />28d. PRONOUNCED DEAD /Hour!
<br />M
<br />ti g o 280. On the basis of examination and•or mvestigalivn, in my opinion death occurred at
<br />the lime, date and place and due to The causelsl staled.
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN COi
<br />YES ❑ NO ❑ UNKNOWN v , 11 YES NO
<br />31. NAME AND ADDRESS OF (PHYSICIAN, HYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEYI frypr. , Pmt)
<br />X cQ.�'U�4v( (Irlr�. /l�G'� �� Cc�S�E
<br />32a. REGISTRAR
<br />I hereby certify this to be a true and correct copy of the original
<br />filed with the State of Nebraska
<br />by
<br />Signed in m resence this day of r
<br />Notary Public
<br />® QENERAL ROTARY-STATE OF NEBRASKA
<br />JAMES R. HECHT
<br />MY COMMISSION EXPIRES OCT. 16. 0005
<br />30.0 WAS CONSENT GRANTED?
<br />X ❑ YES
<br />0 T5 ja n,c , A,�-zF 6
<br />32b. DATE FILEO BY REGISTRAR /Mo.. Oay. Yr.)
<br />JUL 31 2003
<br />0
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