|
LEEGAL: The Northerly One -Half of Lot Four (4), in Block One Hundred Thirty -Three (133),
<br />Union Pacific Railway Company's Second Addition, City of Grand Island; Hall County; Nebraska.
<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 ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE /i), -904" IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. = -
<br />DATE OF ISSUANCE
<br />SEP 16 2005 200509327 ASSISTANTSTAT€]REG 14AR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES- SYSTEM;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALT 4 -
<br />BUREAU OF VITAL. STATISTICS � 9 ?-- 0 4 5 Q
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FlRST MIDDLE LAST
<br />Kenneth Lewis Price Sr.
<br />12. SEX ...... 3 DATE OF OVIH 1iak+M. Ay YAa!i
<br />I
<br />Male _ �1 _22, . 1222
<br />PQ
<br />-n
<br />_
<br />Fredericktown, Ohio
<br />1 41 1923
<br />7. SOCIAL SECURITY NUW9P 88.
<br />m
<br />tttttt�...n.aa�
<br />_ _
<br />i �A n Nuraln` IbnN (RNgenca o Nr (S,tcay, _
<br />c
<br />rn
<br />M. INSIDE CITY LM1R6 So COUNTY OF DEATH
<br />CD
<br />Hame:- 821 N. Oak
<br />Grand I land
<br />I Yes Hall
<br />96 RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CrrY. TOWN OR '.00ATKNI
<br />C7
<br />Ae. so"* CITY LIMB°
<br />N
<br />CD
<br />M
<br />n
<br />n
<br />1 821 1
<br />Z
<br />-
<br />ar
<br />--I
<br />r
<br />CD
<br />Will
<br />Oft-) ISf0yY)
<br />(Specs$,! W00WE0. DIVOR"rFD (SP. I
<br />White
<br />American lit Married_
<br />I._Arclellik Gan _
<br />146. USUAL OCCUPATION (Give *md of work dare dtwag most
<br />of WCH&M
<br />Er
<br />t� EDUCJ1riOtG !rL
<br />- -
<br />EIy a ; ID -tzI tea• ft -: or 5.1
<br />Machinist Foreman
<br />Plant ��
<br />CD
<br />ALLmunitlon
<br />Cn
<br />IS. FATHEP - NAME FIRST v MIDDLE !AST 17.
<br />MOTHER - MAIMN NAME r,A.5T MIDDLE ^� -IAST
<br />Wilson Pr,ce I
<br />mable ,. nial
<br />1S. WAS DECEASED
<br />EVER ri V.S- ARMED FORCES?
<br />.
<br />19. INFORMANT - NAME - MAIL04G ADDRESS (STREET Oil R F.D. IQ. CRY OR TOWN, IMATE. M
<br />IYes, no, or uttk l
<br />I (r yes, give war and data of ""ices)
<br />lArdella
<br />Yes: 1-00-46
<br />10 --3-52
<br />Price -821 N. Oak -Grand Igland, NE. 68861
<br />20a. WJMAL. Ctemahon.Renttrval, 20b. DATE
<br />2DC. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OR TOWN STATE
<br />Co
<br />westlawn Memorial Park _i--. Gr4ad lolladi W.
<br />21. EMdAI R - SIGNATURE & LICENSE NO. 4 j 0
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.O. NO., CITY Da TOMM. STATE, ZIM
<br />Z
<br />A fel- Butler -- Geddes 1123 W. 2nd, Grand Island NE 68801
<br />kA41E AU (ENTER ONLY ONE CAUSE PER LINE FOR (a(, (b), AND (cp 1 awanVl aw aAd a�
<br />PART _
<br />r
<br />DUE TO, OR AS A CONSEQUENCE OF: ■ M0K attd Mrp
<br />Itd
<br />DUE TO, OR AS WCONSEOUIEWE OF: �„ t knienyl rgHr
<br />�/�J 'JOrMr _Met
<br />• r
<br />im
<br />OTHER SIGN CONDITIONS - Condomos np to death but not feleled PART III IF FEMALE. WAS THERE A f
<br />24. AUTOPSY
<br />25 WAS CASE Ri3 TO MEOtCAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS°
<br />:>
<br />Z� EPY� COAONlER9
<br />r 1 Yes C� No �J'
<br />No
<br />NO
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDE'r.,
<br />2fib. DATE OF INJURY (AIo.,DIy, Yr.)
<br />26c, HOUR OF INJURY
<br />26d. DESCRIBE HOW K)URY OCrAI iRED
<br />OR PENDING INVESTIGATION /Spoedyl
<br />i
<br />1
<br />260. INJURY AT WORK
<br />281, PLACE OF INJURY - At hone, farm, $InW, fecbry.
<br />269. LOCATION STREET OP. R.F.D. NO. CITY OR T'CANN STATE
<br />(SpC* Yes w No;
<br />office building. etc. (Sow0y)
<br />11110..
<br />LEEGAL: The Northerly One -Half of Lot Four (4), in Block One Hundred Thirty -Three (133),
<br />Union Pacific Railway Company's Second Addition, City of Grand Island; Hall County; Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE /i), -904" IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. = -
<br />DATE OF ISSUANCE
<br />SEP 16 2005 200509327 ASSISTANTSTAT€]REG 14AR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES- SYSTEM;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALT 4 -
<br />BUREAU OF VITAL. STATISTICS � 9 ?-- 0 4 5 Q
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FlRST MIDDLE LAST
<br />Kenneth Lewis Price Sr.
<br />12. SEX ...... 3 DATE OF OVIH 1iak+M. Ay YAa!i
<br />I
<br />Male _ �1 _22, . 1222
<br />4. CITY AND STATE OF WRTH (N nor in U.S.A., ramo co"jol 54. AGE • LIN BuMxipy
<br />3�a Ivra.n sb MOS. DAYS
<br />,...,,,._... _.
<br />e, TE OF ORTH Me:.1eN. �, YAW
<br />x Ha,RS MINS
<br />Fredericktown, Ohio
<br />1 41 1923
<br />7. SOCIAL SECURITY NUW9P 88.
<br />PLACE OF DEATH
<br />F108W 0 Mp�YIrM ;� ER,Ou09beif 11- 5QA
<br />275 -22 -4493
<br />_ _
<br />i �A n Nuraln` IbnN (RNgenca o Nr (S,tcay, _
<br />8b. FACILITY - NWW (N not Nbd&*da, grra sMd and rk/mder)
<br />8q. CITY, TOWN OR LOCATION OF DEATH
<br />M. INSIDE CITY LM1R6 So COUNTY OF DEATH
<br />/$PICA$, Yee of
<br />Hame:- 821 N. Oak
<br />Grand I land
<br />I Yes Hall
<br />96 RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CrrY. TOWN OR '.00ATKNI
<br />96. STREET AND NUMBER Ikwo" Zip CoaW
<br />Ae. so"* CITY LIMB°
<br />Nebraska
<br />Hall
<br />i Grand Is rid_
<br />1 821 1
<br />Yee air AW
<br />10 RACE - (0.9., WhAs, Black, Ama•ecan Indian,
<br />11. ANCESTRY ;a.g.,Nekan, Mexican, Gomm. ase. t2. MARRIED.NEVER MARP;FA
<br />13. N3.IJE OF SPOUSE AI wok, pv► aaptlM Aptel
<br />Oft-) ISf0yY)
<br />(Specs$,! W00WE0. DIVOR"rFD (SP. I
<br />White
<br />American lit Married_
<br />I._Arclellik Gan _
<br />146. USUAL OCCUPATION (Give *md of work dare dtwag most
<br />of WCH&M
<br />146. KIND OF BUSINESS INDUSTRY
<br />t� EDUCJ1riOtG !rL
<br />- -
<br />EIy a ; ID -tzI tea• ft -: or 5.1
<br />Machinist Foreman
<br />Plant ��
<br />ALLmunitlon
<br />IS. FATHEP - NAME FIRST v MIDDLE !AST 17.
<br />MOTHER - MAIMN NAME r,A.5T MIDDLE ^� -IAST
<br />Wilson Pr,ce I
<br />mable ,. nial
<br />1S. WAS DECEASED
<br />EVER ri V.S- ARMED FORCES?
<br />.
<br />19. INFORMANT - NAME - MAIL04G ADDRESS (STREET Oil R F.D. IQ. CRY OR TOWN, IMATE. M
<br />IYes, no, or uttk l
<br />I (r yes, give war and data of ""ices)
<br />lArdella
<br />Yes: 1-00-46
<br />10 --3-52
<br />Price -821 N. Oak -Grand Igland, NE. 68861
<br />20a. WJMAL. Ctemahon.Renttrval, 20b. DATE
<br />2DC. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OR TOWN STATE
<br />Donow
<br />l I April _.27, 1992
<br />westlawn Memorial Park _i--. Gr4ad lolladi W.
<br />21. EMdAI R - SIGNATURE & LICENSE NO. 4 j 0
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.O. NO., CITY Da TOMM. STATE, ZIM
<br />Z
<br />A fel- Butler -- Geddes 1123 W. 2nd, Grand Island NE 68801
<br />kA41E AU (ENTER ONLY ONE CAUSE PER LINE FOR (a(, (b), AND (cp 1 awanVl aw aAd a�
<br />PART _
<br />r
<br />DUE TO, OR AS A CONSEQUENCE OF: ■ M0K attd Mrp
<br />Itd
<br />DUE TO, OR AS WCONSEOUIEWE OF: �„ t knienyl rgHr
<br />�/�J 'JOrMr _Met
<br />• r
<br />im
<br />OTHER SIGN CONDITIONS - Condomos np to death but not feleled PART III IF FEMALE. WAS THERE A f
<br />24. AUTOPSY
<br />25 WAS CASE Ri3 TO MEOtCAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS°
<br />(5pC'NC�tT'yyY =.r A»)
<br />Z� EPY� COAONlER9
<br />r 1 Yes C� No �J'
<br />No
<br />NO
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDE'r.,
<br />2fib. DATE OF INJURY (AIo.,DIy, Yr.)
<br />26c, HOUR OF INJURY
<br />26d. DESCRIBE HOW K)URY OCrAI iRED
<br />OR PENDING INVESTIGATION /Spoedyl
<br />i
<br />1
<br />260. INJURY AT WORK
<br />281, PLACE OF INJURY - At hone, farm, $InW, fecbry.
<br />269. LOCATION STREET OP. R.F.D. NO. CITY OR T'CANN STATE
<br />(SpC* Yes w No;
<br />office building. etc. (Sow0y)
<br />11110..
<br />270. DATE OF DEATH Day, Yr.)
<br />26m. DATE SIGNED PAP.. Day. Yr.)
<br />20b. TIME OF DEATH
<br />1992
<br />a
<br />-23.A2ril
<br />27b. DA *E SIGNED (1r., Day. W)
<br />21c. TIME OF DEATH
<br />28C. PRONOUNCED DEAD ftib., pay. Y•;
<br />26d. PRONOUNCED DEAD N#Irj
<br />Y
<br />27 April 1992
<br />6.56 a.
<br />E
<br />YYY
<br />o
<br />276. To oe boe of my knowiedpe, s the erne, dale Vd "lace and tlw t
<br />^1i"
<br />2e0 On IN be= of ax&m ,zten "'I. s m my aprnan daNh a =TQd M
<br />Ou hma. date am deco Aw due to rm catAwsl as ed
<br />crluaa(s( pslyd,
<br />p
<br />5:�.,ulkae and TAN P
<br />e and TMO
<br />29a DID TOBACCO USE coNTAicA T64HE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30D WAS CONSENT GRANTED?
<br />0 YES XNO 0 UNKNOWN
<br />0 YES (AID
<br />31. NAME AND ADDRESS PER (PHYSICAN, CORONER'S PHV SICAN OR COUNTY ATTORNEYI !Type or Prlrs/
<br />S. F. m4b. n2444 Faid "ley, Grand Island, NE. 68803
<br />;C-,ity
<br />3211 REGISTRAR
<br />.
<br />32b. DATE FILED BY REGISTRAR Aft. W Y)
<br />APR2 9 V&
<br />
|