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<br />m
<br />In
<br />Nmo .
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE JWPeaTX T ,OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE'L�t�AL1 DEP'OSITORY,'FOR
<br />VITAL RECORDS. x
<br />DATE OF ISSUANCE
<br />FEB I
<br />STANLEY S. COOPER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OF VITAL'STATISTICS
<br />200507732
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />G:
<br />FIRST MIDDLE LAST 12. SEX 13. DATE OF DEATH
<br />a. CI I Y AND STATE OF BIRTH (M nol In U.S.A., rlama country) 5i. AGE • Last Birtday h
<br />n' �a (56 5D Mtl5. DAYS x. HOURSI
<br />1
<br />7. SOCIAL SECURITY NUMBER . I I
<br />Be. PLACE OF DEATH t�,
<br />C H PITAL: 611 Inpatient ❑ ER/Outpaberd Q DOA
<br />507 -48 -5756 OTHER © Nursrnq Home ❑ Residence ❑ Other (Specify)
<br />DATE OF BIRTH (MOnNI, Day, Yearl
<br />December 28, 1936
<br />80. FACILITY - Name (H not institution, give street and number)
<br />PART 111 IF FEMALE, WAS THERE A
<br />Bc. CITY, TOWN OR LOCATION OF DEATH
<br />So. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />St. Francis Medical Center
<br />(Sp ft No)
<br />Grand Island
<br />( Speciy Yes W Noj
<br />Yes
<br />Hall
<br />9a RESIDENCE - STATE
<br />M
<br />zn
<br />Bic . CITY, TOWN OR LOCATION
<br />W. STREET AND NUMBER (Including
<br />Lp Cnde/
<br />9e. INSIDE CITY LIMITS
<br />N� ebraska
<br />Hall
<br />126d.
<br />Cairo
<br />Rt .
<br />1 Box 155
<br />�o "y Yes p, "°)
<br />10. RACE • WEI- While. ENack, American Indian,
<br />1 t. ANCESTRY (e.q.,Nakan, Mexican. German, atc.)
<br />2, MARRIED.NEVER
<br />MARRIED,
<br />c
<br />n
<br />=
<br />!erican (�
<br />It MarrllVeclD rsver yi
<br />�
<br />188. USUAL OCCUPATION !Give kind of work done daring most r
<br />d wprkrirg life, even if refired)
<br />n
<br />Z
<br />Farmer y
<br />Agriculture 1
<br />Elements or Secondary (o. 12) Gdkge (1.1 or 5 +)
<br />1"1
<br />147-FATHER - NAME - -FIRST _ MIpbLE
<br />LAST
<br />17. - MOTHER - MAIDEN NAME
<br />FIRST - .MIDDLE LAST
<br />(a, L O
<br />NK�
<br />_
<br />a
<br />O the beat d my knowWp death 00
<br />n
<br />CA
<br />eausela) stated,
<br />is
<br />the time, dale Md pleG! and dye 10 the Causels) stated
<br />nature and TNN
<br />3:
<br />Si naWra arq Tide
<br />12k DID TOBACCO USE CON`TR'IBUTE THE DEATH?
<br />a. AS A R TISSUE DONATION BEEN CONSIDERED?
<br />306. WAS CONSENT GRANTED?
<br />❑ YES 1DJ/0 ❑ UNKNOWN
<br />❑ YES NO
<br />G YES 0
<br />co
<br />a
<br />�
<br />Cn
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE JWPeaTX T ,OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE'L�t�AL1 DEP'OSITORY,'FOR
<br />VITAL RECORDS. x
<br />DATE OF ISSUANCE
<br />FEB I
<br />STANLEY S. COOPER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OF VITAL'STATISTICS
<br />200507732
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />G:
<br />FIRST MIDDLE LAST 12. SEX 13. DATE OF DEATH
<br />a. CI I Y AND STATE OF BIRTH (M nol In U.S.A., rlama country) 5i. AGE • Last Birtday h
<br />n' �a (56 5D Mtl5. DAYS x. HOURSI
<br />1
<br />7. SOCIAL SECURITY NUMBER . I I
<br />Be. PLACE OF DEATH t�,
<br />C H PITAL: 611 Inpatient ❑ ER/Outpaberd Q DOA
<br />507 -48 -5756 OTHER © Nursrnq Home ❑ Residence ❑ Other (Specify)
<br />DATE OF BIRTH (MOnNI, Day, Yearl
<br />December 28, 1936
<br />80. FACILITY - Name (H not institution, give street and number)
<br />PART 111 IF FEMALE, WAS THERE A
<br />Bc. CITY, TOWN OR LOCATION OF DEATH
<br />So. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />St. Francis Medical Center
<br />(Sp ft No)
<br />Grand Island
<br />( Speciy Yes W Noj
<br />Yes
<br />Hall
<br />9a RESIDENCE - STATE
<br />9b. COUNTY
<br />2U ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />Bic . CITY, TOWN OR LOCATION
<br />W. STREET AND NUMBER (Including
<br />Lp Cnde/
<br />9e. INSIDE CITY LIMITS
<br />N� ebraska
<br />Hall
<br />126d.
<br />Cairo
<br />Rt .
<br />1 Box 155
<br />�o "y Yes p, "°)
<br />10. RACE • WEI- While. ENack, American Indian,
<br />1 t. ANCESTRY (e.q.,Nakan, Mexican. German, atc.)
<br />2, MARRIED.NEVER
<br />MARRIED,
<br />13. NAME OF SPOUSE (!/ wife, give
<br />maiden name)
<br />I"`wn°ite
<br />-
<br />!erican (�
<br />It MarrllVeclD rsver yi
<br />Opal A. Keeler
<br />188. USUAL OCCUPATION !Give kind of work done daring most r
<br />d wprkrirg life, even if refired)
<br />1 sb. KIND OF BUSINESS INDUSTRY
<br />Farmer y
<br />Agriculture 1
<br />Elements or Secondary (o. 12) Gdkge (1.1 or 5 +)
<br />1"1
<br />147-FATHER - NAME - -FIRST _ MIpbLE
<br />LAST
<br />17. - MOTHER - MAIDEN NAME
<br />FIRST - .MIDDLE LAST
<br />18. WAS DECEASED EVE
<br />'
<br />O �Yas, W. yr unk.)
<br />20a. 9DRIAL, Cremalivn,F
<br />Donation
<br />dial
<br />21. EMBA ER - 51GNA1
<br />.23. IMME ) CAU!
<br />PART
<br />I
<br />Otto R. Eggers Laura Emily Peters
<br />i IN U.S. ARMED PORCES7 18 INFORM�NAMEMAILING RESS ( STREET OR R. F .D. NO.
<br />IN yea, give war and dates of services(
<br />20b. DATE
<br />Feb. 6, 1991
<br />IE N.r�l , c:4 3 a
<br />DUE TO. OR AS A CONSEQUENCE OF!
<br />1G1
<br />. CITY OR TOWN, STATE, ZIP)
<br />1 Eggers -Rt.l Box 155 -Cairo, NE. 68824
<br />CEMETERY OR CREMATORY - NAME 200. LOCATION CITY OR TOWN STATE
<br />Westlawn Memorial Park I Grand Island, Nebraska
<br />FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />,fel- Butler- Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />PER LINE FOR (a), (bl, AND Ic)) keervel between OnseOla_nndd death
<br />I
<br />I
<br />Interval between onset and death
<br />UIHLH WUNIMANT CONDITIONS - Conditions = 0 buNng to death but not related
<br />PART
<br />PART 111 IF FEMALE, WAS THERE A
<br />V. AUipPP,�$$$$����''''
<br />25. WAS CASE REFERRED TO MEDICAL
<br />N
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Sp ft No)
<br />EXAMINER OR CORONER?
<br />Yes ❑ No ❑
<br />o
<br />!Specify Yes or No
<br />2U ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />INJURY (Mo.,Day, Yr,/
<br />28c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION tSpedfy/
<br />ji&76XTF7
<br />126d.
<br />Zee. INJURY AT WORK
<br />281. PLACE OF INJURY - At home. term, street, factory,
<br />26q. LOCATION STRrf OR R.F.D. NO CITY OR TOWN STATE
<br />tspecry Yes or NO)
<br />office building. sic. ( Specdy)
<br />278. DATE OF DEATH (W., Day, Yr.)
<br />28a. DATE SIGNED (Afo.. Day, Yr.)
<br />20b. TIME OF DEATH
<br />tl� 3 91
<br />27b. DATE NED (Alp., Day, Yr./
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo., Day, YrJ
<br />28d. PRONOUNCED DEAD (Haar)
<br />(a, L O
<br />NK�
<br />E27
<br />i
<br />a
<br />O the beat d my knowWp death 00
<br />rred at 1 time, date and Ce and due the
<br />2Ba. On the basis d examination And /or mvestgabon, in my Opinion death occurred at
<br />eausela) stated,
<br />is
<br />the time, dale Md pleG! and dye 10 the Causels) stated
<br />nature and TNN
<br />Si naWra arq Tide
<br />12k DID TOBACCO USE CON`TR'IBUTE THE DEATH?
<br />a. AS A R TISSUE DONATION BEEN CONSIDERED?
<br />306. WAS CONSENT GRANTED?
<br />❑ YES 1DJ/0 ❑ UNKNOWN
<br />❑ YES NO
<br />G YES 0
<br />_..... __.. .....�, .... .�.. ,. .,.. . ,.� �vnnp.l 1,YPe yr .rmv
<br />W. L. Fowles M.D. 716 Alpha, Grand Island, NE. 68803
<br />32b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 6 1991
<br />(DIED
<br />
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