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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />FINANCE AND SUPPO�O � � O � � � ^
<br />VITAL S'T'ATISTICS (i)�
<br />CERTIFICATE OF DEATH
<br />I I 01.11 OEM -NAML FI IS'- MIDDLE I.ASI 2 5E% 3 DA1t. U(' ULATH rMurilr ')'7' Yearl
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<br />George Dean Oliver Male December 30, 2004
<br />a Cll'v AND b1A1'1:: OF BINr1l ;l(rru! rr (I ,A nan,a cuunrryl Sa A(,t`. Laal k)�rllldny UNDER 1 YEAR UNDER I DA V a.
<br />DATE OF BIIITH Nlu n O', vua!I
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<br />jYrsl 66 MOS DAYS Sa HOURS' MINS
<br />Grand Island, Nebraska 69 September 17, 1935
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<br />7 St](:IAL SECUHTIY NuN1BL1i da. HLACE OF UEAIH
<br />HOSPITAL' ❑ Irlpallenl OTHER ❑ Nursing Home
<br />507 -36 -2072 _ -
<br />__— _. —_ —_ __— ..__....- 1 /rrnl r'I�lrlulrurr, .Jive s'IraJl d /1<1 ...__
<br />1 ER Outpatient Hesitlencr,
<br />St. Francis Medical Center [�_.1 DOA ❑ on,ar;.5, ,r, ------ - - - - --
<br />i1c CIT "i )OWN QR LOC.Al ION OF DEAl H ad INSIDE CITY LIMITS du COUNTY OF ULAIH
<br />Grand Island Yea ® Np ❑ Hall
<br />9 RF'.SIDFNC'F STATE Jb COUNTY 9e. C'.IIY.I'OWN ORLOCA'IION 9d. SIHEEI ANDNU MBI H llnuludwit, Cod" I 1 INiIL)C Cl I YIIMITS
<br />Nebraska Hall. Grand Island 503 W. 15th St. 68801 1 Y ��" ❑
<br />If) HAr:F la ❑ Wh a Ble, n Ann can InOlar. ANCk
<br />STHY I y.. Italian. Mexican. German, elcl 12. ❑X MARRIED 1-1 WIDOWED 15 NAME Of SPOUSE Iu w �. give rnard�r r dr rcl
<br />NLVLH FJ DIVUHCLU
<br />German /Dutch Anita uandt
<br />White - - - -, ._� � ...........� _- �__.___._....
<br />t4. USUAL OCCUPATION ;L3ive Arrrd ul work Jurrc during rrrU. +r 146 KIND OF BUSINESS INDUSTRY 116 LUUCA IION ISpeclly Drily nrgnest gratlu CUrnNlu(ecll
<br />U /wf,rn:rlr)Irfe. avarr rl rafrredl »'Il yDI a ontl ry Id 121 DUIIHga I 1 ur '.r -i
<br />Supervisor Door Manufacturing i�`t�i (zrac�e
<br />1 G. FATHER - NAME FIRST MIDDLE LAST t / MOTHER FIRST MIDDI.L MAIDEN SURNAME
<br />Charles Oliver Augusta Paustian
<br />16 WAS UE(L'ASFI) IvFf11l l S ARMLU 4UHCLS? 1J .INFORMANT NAME
<br />jYr� I, III y y �• :1 a 1a notes of yery (•aSl
<br />Yes Dates Unknown Anita Oliver
<br />tga INR CIHMANI MAILING ADI)H&S, ISTHEET OR R�F.D NO,CITY OR TOWN FrTATE. ZIP)
<br />03 W. 15th St., Grand Island, Nebraska 68801
<br />U 2u E BAI,MFH -$IGNA I URE d LICENSE NO 21a MFIHODOFDISPOSIT10N z10 . DATE 21c CEMP TE.HY ORCREMATOHV NAME
<br />�. �ttiGt d(:� #lI y 3 X kwrul H , al Wie ert Cemetery
<br />fl1NEHAL HNAMF. — .— ......_..... ❑ ❑ emr v Jan . 3 , 2005 .., J
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<br />_dT"^ 216 CEMETERY OR CREMATORY LOCAI ION N CI IV OH TOWN STAI F
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<br />LU C) ❑ Cramauun ❑ Dunao °r' Nebraska
<br />� C) I�xv�.n�ston- Sondermann F.H. Island, �'
<br />W 22h FUN( RAL HOME ADUH) SS ISI RFET OR R F D NO [ I Y UH 70WN. STATE, ZIP)
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<br />LL_ T 601 N. Webb Road, Grand Island, Nebraska 68803 _
<br />O .ri —_,.. _ �. __.. Inter-al helwran unsel ann OLanr
<br />29 IMMEDIATE CAUSE EN ER ONLY ONE. CAUSE F'F. R LINE FOR lal. 161, AND Icll
<br />o FAR uul,. l0 of n out 02 ti`/,iGu�C _...._._. _ — - �%i�.-
<br />Q I Inlurval between om.1 antl •dean,
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<br />DUF. TO. OR AS A CONSEOULNCE OF Interval b.m. a Dnsel an,, naa111
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<br />OT HER Sl(iNIFICAN'I' cONUI IUNs Cpndll any Canlnhal n}] toile daalh bul np1 releled HA HI' It IF FEMALE. WAS THERE A .4 AUTOPSY 25 WA CASE HEFFRFFI] 1 "U MEDICAL
<br />PAH I PREGNANCY IN THE PAST 3 MON IRS EXAMINER OH (UHUNCH
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<br />)Ayes tf1541 Yes ❑ Na ❑ �Ves ❑ ND �,,_k ;� - -, -_
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<br />210 DATE SIGNED /Mu•. say . Y,) 27c TIME OF DEATH 28c. PRONOUNCED DEAD (Mu. Day, Vr) 21 PRONOUN(:FU DEAD INOUrI
<br />11:37 A.M. M =�
<br />"�7tl I D Intl De9l of my hnowlen IIAI'119 rred aline llnle 1 and place and due ID the ° s u 2BeW On the baSIS DI exarllulallpn and Ur InvHa4gallUn, m ❑,y opinion death
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<br />eauyel+i 9lalncl. � the lime. tlale and place and due ID me tasse(s) stated.
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<br />� ISl�nawre and Ttla) ► ~ ISr nalwe end Tillel ► —.._.. _.._. -._
<br />2g DID TOBACCO USE CONTRIBUTE TO 30.a HqS GROAN OR TISSUE DONATION BEEN CONSIDERED'? 30.b WAS CONSENT GRANTFP?
<br />�.� YES ❑ NO ❑ UNKNOWN �,�-. ❑ YES � NU X. ❑ YES � NO
<br />31 NApdE _ANQ.�y)k1�S6_[JF.CEHTIFIER (PHYSICIAN, CUHONkH 5 PHYSICIAN OR COUNTY A7TORNEYI /rylu+Or Pont)
<br />Or. David R. Colan,_MwD., 729 N. Custer Grand Island NE 6$$03
<br />HF'('Itil'RAR 32b DATE FILED BY RE(i1S'] 'HAH (Mo.
<br />a. DATE SIGNED /MU Day YY1 26p TIMk� OF DEATH
<br />- December 30, 2004
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<br />2(�e 26d UA I L OF INJURY (MU. Day Yr.) GbC. HUUH Ur INJLIHY M FD. Iat5l.ryrnt nuyv rrv�unl uwunncu
<br />�... .VCripenl a undalannlnatl
<br />ulCiGe Hurldlnl 6e INJURY AT WORK ..� 26) PACE F INJURY ......._ —, — _.......,— — __._...,...... — _...._... ...
<br />I 2 LL P At hanra, lean. suael. factory 26q LOCATION STREET OR R.F D. NO l;ll Y OR TOWN STATE
<br />pNlr;e building. 61c lSpecilyJ
<br />_7u [1niE OF DEATH IMO peg Yr./ 28
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<br />Notary
<br />I hereby certify this to be a true and correct copy of the original
<br />filed with the State of Nebraska �
<br />Signed in esence thi �. day of
<br />TERRY L. t.OSC.HEN a ....•a
<br />MY COMMISS,ON EXPIRES
<br />May 2, 20X
<br />Public
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<br />Notary
<br />I hereby certify this to be a true and correct copy of the original
<br />filed with the State of Nebraska �
<br />Signed in esence thi �. day of
<br />TERRY L. t.OSC.HEN a ....•a
<br />MY COMMISS,ON EXPIRES
<br />May 2, 20X
<br />Public
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