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<br />ERR■
<br />1
<br />DATE OF DEATH (Moe, Dar, Yr.)
<br />Reynold Burton Barnes
<br />12, Male
<br />=
<br />1
<br />RACE— (e.q., White, Block, American
<br />ORIGINIDESCENT(e.g., Italian, Mexican, I
<br />AGE —Left Rin6day
<br />LRNDER 1 YEAR I UNDER 1 DAY
<br />rQ
<br />MOS. i DAYS
<br />HOURS. FINS-
<br />Yttdlatti ete3
<br />M
<br />(Yr$.)
<br />s. a
<br />s, American
<br />ba. 71
<br />:.
<br />7 1915
<br />(S) =
<br />CITIZEN OF WHAT COUNTRYIMARRIED
<br />, NEVER MARRIED,
<br />NAME OF SPOUSE (Nuri(r, give we' a6ae)
<br />c
<br />n
<br />WIDOWED, DIVORCED(Speci/yj
<br />Married
<br />Roberts
<br />R
<br />9.
<br />,D
<br />,.Kathryn
<br />rn
<br />( _
<br />OF DEATH
<br />505 -18 -6213 ofworkinglk,ev niiffretire) �` General
<br />Construct
<br />z
<br />12. 19a. p 13b.
<br />L O
<br />dg.
<br />CITY, TOWN OR LOCATION OF DEATH
<br />IN310E CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION — Naar (Il net in either, M
<br />HOW OR INST. Indicate DOA, 1
<br />Hastings
<br />(Sp i Yat or No)
<br />give et and amber) OmpnieNte
<br />114d. arytanna�n Memorial Hosp
<br />-or Ret , Inpawe" (Specify) l
<br />Inpatient
<br />,yes
<br />• ,de.
<br />RESIDENCE —STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />CJ -4
<br />CD
<br />Nebraska 1141b.
<br />Hall
<br />lift. Doniphan
<br />T=T1
<br />>
<br />FATHER—NAME M17DLE LAST MOTHER— MAIDEN NAME FIRST M10011 LAST
<br />Guy Addison Barnes 117, Gertrude Georgia Gorin
<br />WAS DECEASED EVER IN U.S. ARMW FORCES? INFORMANT -- NAME — RELATIONSHIP — MAILING ADDRESS (STREET OR R.F.D. NO., C!" OR TOWN, STATE, ZM)
<br />(Vet, w, or rnk) (If yet, give wet end date at tnvice)
<br />,
<br />BURIAL, Cremation, Removal
<br />n
<br />CEMETERY OR CREMATORY —NAME
<br />to CITY OR TOWN STATE
<br />no urial
<br />April 22, 1987
<br />20c. Cedar View Cemetery
<br />wd. Doniphan, Nebraska
<br />ALM — NATURE A LICENSE NO. Soo
<br />FUNERAL NOME —NAME AND ADDRESS (STREET OR R.F.D. NO.. 4VTY OR TOWN, STATE, ZM
<br />71
<br />Apfel- Butler- Geddes 1123 W. 2nd Grand Island, NE. 6880:
<br />DATE ewv 7 Ms., Dar, r,)
<br />cD
<br />OF DEATH
<br />230. —X2
<br />L �
<br />24a. 24b.
<br />M(
<br />DATE, SIGNED (Mo., Day, Yr.) R50 DFATH
<br />PRONOUNCED DEAD PRONOUNCEDDEAD(hYOM
<br />y( OiiiNaS
<br />r^
<br />7
<br />o
<br />(Moe, pay, Yr.)
<br />23b. ! /` 29c. M
<br />Z
<br />on d' e bath of e.awMatie. andh• :•veNigotwo, a wy apiniee deWk eoew.ed al
<br />Me K�we, does and piece and dw to tM caveat) »p+ed.
<br />f
<br />Corti Me of knowledge, death occurred at the Mau. does o lap and u�
<br />.2
<br />13
<br />/'�j /n
<br />I gall (Signature and Time)
<br />210. (Signature and Tide) N
<br />ANp A E CE ITIFIER (PHYSICIAN, CORWJrS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David L. Howe M.D. Hastings Medical Park, 2115 N. Kansas, Hastings, NE. 68901
<br />REGISTRAR
<br />DATE RECE BY REGISTRAR (Mo., Day, Yr.)
<br />i'
<br />APR 2 7
<br />26a. (Si walan)
<br />CTI
<br />2 IMMEDIATE CAUSE (ENTER ONLY ONE CA E PER LINE FOR ( , (b), AND (c)) Worval ce►ween eneM end ckrel6
<br />.,
<br />DUE TO, OR AS A CON3NMENCE OF: : esser.el betwee eweel work tkoM
<br />L 1 r 1
<br />)L4
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval benvew entot ead drrtb
<br />(c)
<br />PART OTHER SIGNOICAW CON011IONS—Condition caetdbvting to death bat not related
<br />H )
<br />F5 `
<br />-Y%
<br />A CT)
<br />CD
<br />Yes � No ❑ 2B.
<br />'0
<br />ueg* Yoe or NO) �+�y
<br />Z4. ' " t7
<br />ACCT NI, SWCIDE, CIDl, UN ..
<br />DATE OF INJURY (MO., y, Vt.)
<br />HOUR OF INIURY "scoot
<br />NOW IN11M11 DCCLNMEb
<br />aR ►ENDMJO INVESTIGATION. (Spocifr)
<br />rri
<br />900.
<br />306.
<br />M
<br />ALT WORK
<br />(Spas* Teo « NO)
<br />INJURY—:G heme. le., ~. fecesrr.
<br />office building, etc. (SpecNr)
<br />LOCATION STREET W R.F.O. We. CITY OR TOVYN "A"
<br />BDI.
<br />--a
<br />N
<br />0
<br />Cf)
<br />LEGAL DESCRIPTION: Lot Eight (8), Block Ten (10), Original Town of Doniphan,
<br />Hall County, Nebraska.
<br />2005029'72
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD.DN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTS= SE_C776Pk- _WH1CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE
<br />f S DER
<br />MAR 3 n 2005 ASSIS rAiftTkT0tEd4T#AR
<br />LINCOLN, NEBRASKA HEALTH AMID= mj"#sk00cE30YS#M
<br />STATE OF NEBRASKA - DEPARTMENT OF NFL" N',
<br />BUREAU OF VITAL STATISTICS __ ( n 3 9 A
<br />CERTIFICATE OF DEATH,
<br />V f7 `f J
<br />DECEDENT--NAME FIRST LAST
<br />SEX
<br />DATE OF DEATH (Moe, Dar, Yr.)
<br />Reynold Burton Barnes
<br />12, Male
<br />13. Aril 19 1987
<br />1
<br />RACE— (e.q., White, Block, American
<br />ORIGINIDESCENT(e.g., Italian, Mexican, I
<br />AGE —Left Rin6day
<br />LRNDER 1 YEAR I UNDER 1 DAY
<br />DATE OF BIRTH (Me., Day, Yr.)
<br />MOS. i DAYS
<br />HOURS. FINS-
<br />Yttdlatti ete3
<br />yawn, ete.)(Sptec( /y)
<br />(Yr$.)
<br />s. a
<br />s, American
<br />ba. 71
<br />:.
<br />7 1915
<br />CITY AND STATE OF BIRTH (if net in U.S.A.,
<br />CITIZEN OF WHAT COUNTRYIMARRIED
<br />, NEVER MARRIED,
<br />NAME OF SPOUSE (Nuri(r, give we' a6ae)
<br />aware ce retry)
<br />Xurara, Nebraska
<br />U.S.A.
<br />WIDOWED, DIVORCED(Speci/yj
<br />Married
<br />Roberts
<br />R
<br />9.
<br />,D
<br />,.Kathryn
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done daring mnct KIND
<br />OF BUSINESS OR INDUSTRY
<br />OF DEATH
<br />505 -18 -6213 ofworkinglk,ev niiffretire) �` General
<br />Construct
<br />[COVOINTY
<br />o Adams
<br />12. 19a. p 13b.
<br />L O
<br />dg.
<br />CITY, TOWN OR LOCATION OF DEATH
<br />IN310E CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION — Naar (Il net in either, M
<br />HOW OR INST. Indicate DOA, 1
<br />Hastings
<br />(Sp i Yat or No)
<br />give et and amber) OmpnieNte
<br />114d. arytanna�n Memorial Hosp
<br />-or Ret , Inpawe" (Specify) l
<br />Inpatient
<br />,yes
<br />• ,de.
<br />RESIDENCE —STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LI MITS
<br />Nebraska 1141b.
<br />Hall
<br />lift. Doniphan
<br />tad. P.O. Box 134
<br />15 fires j
<br />FATHER—NAME M17DLE LAST MOTHER— MAIDEN NAME FIRST M10011 LAST
<br />Guy Addison Barnes 117, Gertrude Georgia Gorin
<br />WAS DECEASED EVER IN U.S. ARMW FORCES? INFORMANT -- NAME — RELATIONSHIP — MAILING ADDRESS (STREET OR R.F.D. NO., C!" OR TOWN, STATE, ZM)
<br />(Vet, w, or rnk) (If yet, give wet end date at tnvice)
<br />„_NO I IpKathryn Barnes - Wife -P.O. Box 134-Doniphan, NE. 68832
<br />BURIAL, Cremation, Removal
<br />DATE
<br />CEMETERY OR CREMATORY —NAME
<br />to CITY OR TOWN STATE
<br />no urial
<br />April 22, 1987
<br />20c. Cedar View Cemetery
<br />wd. Doniphan, Nebraska
<br />ALM — NATURE A LICENSE NO. Soo
<br />FUNERAL NOME —NAME AND ADDRESS (STREET OR R.F.D. NO.. 4VTY OR TOWN, STATE, ZM
<br />71
<br />Apfel- Butler- Geddes 1123 W. 2nd Grand Island, NE. 6880:
<br />DATE ewv 7 Ms., Dar, r,)
<br />DATE SIGNED (Moe Day, Yr.) HOUR
<br />OF DEATH
<br />230. —X2
<br />L �
<br />24a. 24b.
<br />M(
<br />DATE, SIGNED (Mo., Day, Yr.) R50 DFATH
<br />PRONOUNCED DEAD PRONOUNCEDDEAD(hYOM
<br />y( OiiiNaS
<br />r^
<br />7
<br />o
<br />(Moe, pay, Yr.)
<br />23b. ! /` 29c. M
<br />Z
<br />on d' e bath of e.awMatie. andh• :•veNigotwo, a wy apiniee deWk eoew.ed al
<br />Me K�we, does and piece and dw to tM caveat) »p+ed.
<br />f
<br />Corti Me of knowledge, death occurred at the Mau. does o lap and u�
<br />.2
<br />13
<br />/'�j /n
<br />I gall (Signature and Time)
<br />210. (Signature and Tide) N
<br />ANp A E CE ITIFIER (PHYSICIAN, CORWJrS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David L. Howe M.D. Hastings Medical Park, 2115 N. Kansas, Hastings, NE. 68901
<br />REGISTRAR
<br />DATE RECE BY REGISTRAR (Mo., Day, Yr.)
<br />APR 2 7
<br />26a. (Si walan)
<br />266.
<br />2 IMMEDIATE CAUSE (ENTER ONLY ONE CA E PER LINE FOR ( , (b), AND (c)) Worval ce►ween eneM end ckrel6
<br />.,
<br />DUE TO, OR AS A CON3NMENCE OF: : esser.el betwee eweel work tkoM
<br />L 1 r 1
<br />)L4
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval benvew entot ead drrtb
<br />(c)
<br />PART OTHER SIGNOICAW CON011IONS—Condition caetdbvting to death bat not related
<br />H )
<br />PART IR. 1F FPA"E WAS TNERF A AUIOISY
<br />PREGNANCY 114 T141 PAST S MONTHST (Specar
<br />Yr w tes)
<br />WAli CAFE REFERRED TO
<br />E lR p! conom !
<br />k Z �! t
<br />Yes � No ❑ 2B.
<br />'0
<br />ueg* Yoe or NO) �+�y
<br />Z4. ' " t7
<br />ACCT NI, SWCIDE, CIDl, UN ..
<br />DATE OF INJURY (MO., y, Vt.)
<br />HOUR OF INIURY "scoot
<br />NOW IN11M11 DCCLNMEb
<br />aR ►ENDMJO INVESTIGATION. (Spocifr)
<br />900.
<br />306.
<br />M
<br />ALT WORK
<br />(Spas* Teo « NO)
<br />INJURY—:G heme. le., ~. fecesrr.
<br />office building, etc. (SpecNr)
<br />LOCATION STREET W R.F.O. We. CITY OR TOVYN "A"
<br />BDI.
<br />V \
<br />
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