|
STATE OF NEBRASKA - DEPARTMENT-40E-HEALTH
<br />BUREAU OF VITAL STATISTICS'- ..:
<br />CERTIFICATE OF DEATH- y
<br />I -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH !Month Day Year)
<br />LtUtUtN
<br />Alvin Oscar Dickey Male April 4, 1995
<br />4. CITY AND STATE OF BIRTH MOM h U.S.A.. name c fry) 5a AGE - LaSt Bmlday UNDER 1 YEAR UNDER 1 DAY 6. DATE CF BIRTH !Mahal. Day Year) v
<br /><r ti
<br />C71 cr,
<br />�? --4
<br />T ......-
<br />506 -26 -5640 HOSPITAL: ® Inpapeld OTHER ❑ NlusngH,m.
<br />...
<br />tip. FACILITY • NaM /Hnd rnSh"04 give snw and nydCer) ❑ ER OuNMpent ❑ Residence
<br />St. Francis Medical Center ❑ 0OA ❑ OmeI /speceyl
<br />x, raTY. oR LOCArInri oF- oeATFI ed INS.D cm uMiTs ee. couNTr of Dr AT„
<br />-,
<br />99. RESIDENCE - STATE 9b. COUNTY 9c. CRY, TOWN OR LOCATION 9d. STREET AND NUMBER (AICkA*VZrp Cadet 9e INSIDE CITY LIMITS
<br />---I
<br />� v
<br />10. RACE •N.0. Whet. Slack. Amer a aldian. 11. ANCESTRY is g.. IMlisn, Mexican, G&nwL at) 12. � MARRIED ❑ WIDOWED 13 NAME OF SPOUSE !M wr/e. grvt meederr name!
<br />ry
<br />14a USUAL OCCUPATK„N lGnw Aid d aanJr OarIB dwirg nrcw! 40. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Spec/y mly hlghw grade cdm~j
<br />d adrkxng 4Ta, a wrr / AMMd)
<br />C
<br />y 71 �,',...
<br />C:)
<br />_[
<br />(Yet: no. or Lwk) IN pa, 9M war and dates of terviceal
<br />No Patricia Dickey
<br />marl
<br />2504 W 10th, Grand Island, Nebraska 68803
<br />E
<br />20. EM - SIGNATURE 6 LICENSE NO. 17Z 21a. METHOD OF DMON 21h. DATE 21C. CEMETERY OR CREMATORY NAME
<br />® ealral ❑ mov
<br />Real A ril 8, 1995 St. Josepht s Catholic Cemetery
<br />,V,�
<br />Govier Brothers Mortuary, Inc. ❑Cr""'°n ❑Dwaw Broken Bow, Nebraska
<br />22b. FUNERAL HDME ADDRESS (STREET OR FLF.D. NO., CITY OR TOWN, STATE. TIP)
<br />542 South 9th Avenue, P.O. Box 665, Broken Bow, Nebraska 68822
<br />M CA
<br />al. M, AND fel) Irtervdl p1ea1 and death
<br />I
<br />(al
<br />I
<br />WET . OR AS A CONSC^IXIE OF j Interval between and death
<br />I
<br />- ,•__i111 -... _ .,_.ti _` '`.ter- _ . �,�� c ,.. ._� s..J.t-Y'- _ i -_ 1 ._..�`J''�sF'��"i. I --.• -, � ::. � ..
<br />DUET , OR AS A CONSEQUENCE OF I a1 behvean Mttak and death
<br />rQ
<br />@
<br />n y
<br />°`
<br />2a AUTOPSv
<br />25 WAS CASE REFERRED TO MEDICAL
<br />CD
<br />��a
<br />@ �Ia�Ma
<br />EXAMINER OR CORONER?
<br />111
<br />10.54) Yes Nd
<br />f ..'7
<br />Yes
<br />co
<br />co
<br />26c.
<br />5PA
<br />0. DESCRIBE HOW INJU RY OCCURRED
<br />❑ Undalrrrwled
<br />71
<br />�
<br />Q �
<br />CD
<br />❑ Sacde ❑ P.,d-N
<br />28e. INJURY AT WORK
<br />261 PLACE OF MU �A= Irm sr. Iaclyy
<br />dFce brAl6ng
<br />co
<br />❑ Mvesppeaian
<br />Yes ❑ Np ❑
<br />w
<br />co
<br />co
<br />288. DATE SIGNED JA4o. Lay Yr.)
<br />28b. TIME OF DEATH
<br />IS
<br />g
<br />M
<br />27b. DATE NED / .. pay. yrr
<br />7c. TIME OF DEATH
<br />WHEN THIS COPY CARRZES THE RASED SEAL OF THE NEBRASKA STA TEDEPART46VT'lWHEAL TH,
<br />M. PRONOUNCED DEAD /Mpw)
<br />E
<br />G
<br />C) M
<br />9
<br />B
<br />ZT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON_ -MME Mw THE STATE
<br />M
<br />C1
<br />27d To heat d kq krowtadge dead) red at tree Grtne, and place and dye 10 Me
<br />236. On Ihd basis of Bxammaten drd' pn xNCAyaeon, m nay Opngn dead) pcCdr/ed M
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS TgEjE AL OF1 lS - Y FOR
<br />cautelsl staled.
<br />a
<br />Iha amt, dale drM pace and due b the ranaelsl shWd-
<br />gtaftme and Tale
<br />VITAL RECORDS.
<br />and Tills
<br />29 DID 7pBACCO
<br />USE CONTRIBUTE TOT DEAT
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />DATE OF ISSUANCE
<br />200508488
<br />,
<br />-
<br />❑ YES NO
<br />-5
<br />Dr. Gordon Hrnicek, 729 Custer Avenue, Grand Island, NE 68803
<br />_
<br />32a REGISTRAR
<br />APR 141995
<br />. = _
<br />APR 111995
<br />STANLL9�,5. COOPER, D/R��OR
<br />LINCOLN, NEBRASKA
<br />$UREAGy- OF VITACSTATrTICS
<br />STATE OF NEBRASKA - DEPARTMENT-40E-HEALTH
<br />BUREAU OF VITAL STATISTICS'- ..:
<br />CERTIFICATE OF DEATH- y
<br />I -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH !Month Day Year)
<br />LtUtUtN
<br />Alvin Oscar Dickey Male April 4, 1995
<br />4. CITY AND STATE OF BIRTH MOM h U.S.A.. name c fry) 5a AGE - LaSt Bmlday UNDER 1 YEAR UNDER 1 DAY 6. DATE CF BIRTH !Mahal. Day Year) v
<br />(Ym I 56. NOS. DAYS 5C. HOURS RAINS
<br />Hemin ford, Nebraska 66 February 26, 1929
<br />7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH ^-
<br />T ......-
<br />506 -26 -5640 HOSPITAL: ® Inpapeld OTHER ❑ NlusngH,m.
<br />...
<br />tip. FACILITY • NaM /Hnd rnSh"04 give snw and nydCer) ❑ ER OuNMpent ❑ Residence
<br />St. Francis Medical Center ❑ 0OA ❑ OmeI /speceyl
<br />x, raTY. oR LOCArInri oF- oeATFI ed INS.D cm uMiTs ee. couNTr of Dr AT„
<br />Grand Island Yp ® No ❑ Hall
<br />99. RESIDENCE - STATE 9b. COUNTY 9c. CRY, TOWN OR LOCATION 9d. STREET AND NUMBER (AICkA*VZrp Cadet 9e INSIDE CITY LIMITS
<br />Nebraska I Hall Grand Island 12504 W. 10th 68803 Yee © No ❑
<br />10. RACE •N.0. Whet. Slack. Amer a aldian. 11. ANCESTRY is g.. IMlisn, Mexican, G&nwL at) 12. � MARRIED ❑ WIDOWED 13 NAME OF SPOUSE !M wr/e. grvt meederr name!
<br />e10.11SPecAy1 Ispecdyl NEVER
<br />White Bohemian /Welsh /Danish DIVORCED Patricia Hanneman
<br />14a USUAL OCCUPATK„N lGnw Aid d aanJr OarIB dwirg nrcw! 40. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Spec/y mly hlghw grade cdm~j
<br />d adrkxng 4Ta, a wrr / AMMd)
<br />Elemernary ^ Sxanddry (0 -171 Co" 11 -4 or 5.1
<br />I'Bur
<br />Agent/Operator l in ton Northern Railroad 1L
<br />16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Oscar Dickey Wilma Eva Keane
<br />ld WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME
<br />(Yet: no. or Lwk) IN pa, 9M war and dates of terviceal
<br />No Patricia Dickey
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R,F.D. NO., CITY OR TOWN. STATE. ZIP(
<br />2504 W 10th, Grand Island, Nebraska 68803
<br />E
<br />20. EM - SIGNATURE 6 LICENSE NO. 17Z 21a. METHOD OF DMON 21h. DATE 21C. CEMETERY OR CREMATORY NAME
<br />® ealral ❑ mov
<br />Real A ril 8, 1995 St. Josepht s Catholic Cemetery
<br />22a. ERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Govier Brothers Mortuary, Inc. ❑Cr""'°n ❑Dwaw Broken Bow, Nebraska
<br />22b. FUNERAL HDME ADDRESS (STREET OR FLF.D. NO., CITY OR TOWN, STATE. TIP)
<br />542 South 9th Avenue, P.O. Box 665, Broken Bow, Nebraska 68822
<br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR
<br />PART �
<br />al. M, AND fel) Irtervdl p1ea1 and death
<br />I
<br />(al
<br />I
<br />WET . OR AS A CONSC^IXIE OF j Interval between and death
<br />I
<br />- ,•__i111 -... _ .,_.ti _` '`.ter- _ . �,�� c ,.. ._� s..J.t-Y'- _ i -_ 1 ._..�`J''�sF'��"i. I --.• -, � ::. � ..
<br />DUET , OR AS A CONSEQUENCE OF I a1 behvean Mttak and death
<br />(CI I
<br />PART OTHER SIGNIFICANT CONDITIONS - Cprnievns carMdhteing q Ins dean but nEn"a"O
<br />I If FEMALE. WAS THERE A
<br />2a AUTOPSv
<br />25 WAS CASE REFERRED TO MEDICAL
<br />ANCY IN THE PAST 3 MONTH$?
<br />EXAMINER OR CORONER?
<br />10.54) Yes Nd
<br />Yes Np
<br />Yes
<br />26b. DATE OF INJURY (W,. pay. Yi)
<br />26c.
<br />5PA
<br />0. DESCRIBE HOW INJU RY OCCURRED
<br />❑ Undalrrrwled
<br />.
<br />❑ Sacde ❑ P.,d-N
<br />28e. INJURY AT WORK
<br />261 PLACE OF MU �A= Irm sr. Iaclyy
<br />dFce brAl6ng
<br />269. LOCATION STREET OR RF D No CITY OR TOWN STATE
<br />❑ Mvesppeaian
<br />Yes ❑ Np ❑
<br />27a. DATE OF TH (Mb.. pay. Yc)
<br />288. DATE SIGNED JA4o. Lay Yr.)
<br />28b. TIME OF DEATH
<br />IS
<br />g
<br />M
<br />27b. DATE NED / .. pay. yrr
<br />7c. TIME OF DEATH
<br />2Bc. PRONOUNCED DEAD (Ala.. Day yr i
<br />M. PRONOUNCED DEAD /Mpw)
<br />E
<br />G
<br />C) M
<br />9
<br />B
<br />M
<br />C1
<br />27d To heat d kq krowtadge dead) red at tree Grtne, and place and dye 10 Me
<br />236. On Ihd basis of Bxammaten drd' pn xNCAyaeon, m nay Opngn dead) pcCdr/ed M
<br />cautelsl staled.
<br />a
<br />Iha amt, dale drM pace and due b the ranaelsl shWd-
<br />gtaftme and Tale
<br />and Tills
<br />29 DID 7pBACCO
<br />USE CONTRIBUTE TOT DEAT
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES �NO NKNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYS0AN OR COUNTY ATTOMEYI (rype or Prwi
<br />Dr. Gordon Hrnicek, 729 Custer Avenue, Grand Island, NE 68803
<br />_
<br />32a REGISTRAR
<br />32b OAtEFILEDB` ?EGISTRAR (W... Day YrJ
<br />APR 111995
<br />-
<br />LEGAL DESCRIPTION: Lot One (1) in Block Sixteen (16) West Park Addition
<br />to the city of Grand Island, Hall County, Nebraska
<br />
|