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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST 3E'Cry6N�WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS,
<br />DATE OF ISSUANCE
<br />AIANLE". COOPER
<br />7/15/2004 200504513
<br />ASSISTANT ST`Af REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEItV7CR5Fii ANtE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH n A n7 C; .q 1
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Roland Raymond Newman
<br />Male
<br />July 8, 2004
<br />4, CITY AND STATE OF BIRTH /tlnot in U.S.A.. name country)
<br />59. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Month. Day. Year)
<br />North Loup, Nebraska
<br />(Yrs.) 69
<br />7
<br />Sb. MOS. DAYS
<br />Sc, HOURS' MINS,
<br />April 20, 1935
<br />1
<br />7: SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL: Inpatient OTHER Nursing Home
<br />508 -38 -2118
<br />"' T
<br />ER Outpatient Residence
<br />3b. FACILITY -Name (Ynot mstifution, give street and number)
<br />Brawn County Hospital
<br />© DOA ❑ Other(Specdv)
<br />- 8c. CITY. TOWN OR LOCATION OF DEATH
<br />6tl., INSIDE CITY LIMIT$
<br />ee. COUNTY OF DEATH
<br />Ainsworth.
<br />Ye] No ❑
<br />Brown-.- .:.:, ...,
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9t. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1116 W. 18th St. 68801
<br />Yesjj No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le.q.. Italian. Mexican, German, etc)
<br />12. Z] MARRIED 1-1 WIDOWED
<br />13. NAME OF SPOUSE (if wee, give maiden name)
<br />etc.) (Specify)
<br />(Specify)
<br />German /Polish
<br />NEVER DIVORCED
<br />DMARRIED
<br />Jolene Rogers
<br />White
<br />14a. USUAL OCCUPATION (Give kind of murk done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify Only highest grade completed).
<br />I men dry Or S"'ond ry (0 -12) College I1 -4 or 5-I
<br />of working life, even d retired)
<br />-Construction Supervisor
<br />Diamond En ineerin�1tI
<br />Gra�e
<br />16. FATHER -NAME IHHSI MIUULt LAa I I r. mu ncn rrn51 Mruute Mnwen --vi.
<br />Henry_ Newman Martha Kasmicki
<br />-_ 161 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME
<br />(Yes. no, or unit.) (It yes. give war and dates of services)
<br />No ---- - - - --- Jolene Newman
<br />19b, INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />116 W. 18th St., Grand Island Nebraska 68801
<br />20. BALMFR - SI AY J 8 LICENSE NO, 21 a. METHOD OF DISPOSITION 21b, DATE 21 c. CEMETERY OR CREMATORY NAME
<br />#1105 X� Burial ❑ FemovaiJuly 12, 2004 Westlawn Memorial Park
<br />22 FUNERAL HOME • NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sandermann F.H. ❑Cremation Dtlnanpn Grand , Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO,. CITY OR TOWN, STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 --4050
<br />_ 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND fell I Interval between onset and death
<br />PART
<br />a fit. 1c, (7,g Gy'v��°LF�G�%�/
<br />DUE TO, OR AS A CONSEQUENCE OF f Intery I between onset and death
<br />Ib) Gc �. Y6'? f'G(� v7� G /l/% Y�PY' G 1/�% C !N'
<br />DUE TO. OR AS A CONSECUF,NCF OF r Interval between onset ano death
<br />(c) I 1
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PAR f�/�/ t - �. ,/„,I�i- PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />II G'{"?.�� -es'7 (Ages 10 -54) Yes No Yes 17 No Yes n No
<br />26a. 264. DATE OF INJURY (A4o.. Day. YrJ 26c. HOUR OF INJURY Zed. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident F-1 Undetermined M
<br />1 ❑ Suicide ❑ Pending 26e. INJURY AT WORK 261, PACE OIF INJURY -sAt hoe1�r . farm, street. factory 25g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />o ce hui dlrg, etc. / pectryf
<br />Homicide Investigation Yes No ❑
<br />27a. DATE OF DEATH /Mo. Day. YrJ 28a. DATE SIGNED (Mo.. Day. Vr) 284. TIME OF DEATH
<br />�, lJ -;7 (Jll.. g M
<br />y } 27b. DATE SIGN /Mo.. De ' YrJ 27c. TIME OF DEATH ("�, } 28c, PRONOUNCEO DEAD (Mo.. Day, Yr.) 28d, PRONOUNCED DEAD (Hour)
<br />Gj
<br />� -7 L' M
<br />g�
<br />� 27d. To the best of my knowledge. dead) oc ur at the time, date and place and due to the ° � � 28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />cause($) Stated. b the time, date and place and due to the causels) stated.
<br />(Signature and Title) ► t (Si nature and to
<br />29. DID TOBACCO 1-"CONTRIBUTE TO THE DEATH? 3D.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES ❑ NO ❑ UNKNOWN YES ❑ NO
<br />31. Nr ME AND ADDRESS CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) V
<br />32a. RFGISTRAR / 32b. Df
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES ® NO
<br />I
<br />MIAzU BY Ht(jilb I HAH IMa. Uay. rr.)
<br />JUL 13 2004
<br />
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