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<br />Rev. 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />Interval between onset and death
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<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year/
<br />John H. Conant
<br />Male
<br />July 15, 1999
<br />4. CITY AND STATE OF BIRTH /ltnot kr U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />16. DATE OF BIRTH /Monk Day, Year/
<br />Albion, Nebraska
<br />(Yrs.) 89
<br />y
<br />Sb. MOS. DAYS
<br />SC. HOURS' MINS.
<br />(.
<br />May 24/ 1710
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -07 -5417
<br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home
<br />Yes No
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Nnot institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specdyl
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. 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 />616 West Louise 6880
<br />X❑ ❑
<br />❑ Homicide Investigation
<br />Yes ❑ No ❑
<br />Yes No
<br />10. RACE - (e.g., White. Black, American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (If wife. give maiden name)
<br />etc.) (Spa
<br />ite
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />Martha Scholz
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retkedl
<br />New Editor
<br />Grand Island Independent
<br />Eleme i a or Secondary l0 -12) Colleg 11 -4 or 5-1
<br />16. FATHER -NAME FIRST MIDDLE UST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />e Daniel Conant 1
<br />Agnes Hyland
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />IYYesr.nk.l Ill yea.gi -15 412 )f s10- 7 -45
<br />Martha Conant
<br />I 9b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />616 West Louise, Grand Island, NE. 68801
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<br />20. EMBALME IG TUREB EMe
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORYNAME
<br />Gs-c(„
<br />® Burial ❑ Removal
<br />July 19, 1999
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOME - NA
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑ cremate^ ❑ Donallon
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. 1
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<br />Interval between onset and death
<br />? !7a i,,/r
<br />FOR VITAL STATISTICS USE ONLY
<br />Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV...........................
<br />NSC...................................................................................:....................................................................................................... ............................... .........................Census Tract No.
<br />Work...................................................................................................................
<br />U C................ ....................................................................................................................................................................................................................... ........................................................
<br />Reject ................................................................................................. ................ ............................... . .
<br />...... ...............................
<br />4 Printed with soy Ink on recycled paper
<br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE
<br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA.
<br />�ER-GfEDDES_OUNEMI HOME BU
<br />GENERAL NOTARY-State of Nebraska
<br />III RAYMOND A. OSEKA
<br />My Comm. Exp. Nov. 27, 2004
<br />,Lot One Hundred 'Ninety Two (192), in West Lawn, an Addition to the City of
<br />Grand Island, Hall County, Nebraska.
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />_6776.
<br />OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />/a PREGNANCY
<br />II �\ , , �/� ' �+
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONE ?
<br />C (J �•�/�/� i
<br />)Ages tO -541 Yes Na
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Ma. Day. Yr.1
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
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<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />LLqq EE p
<br />26L o8ice 6uOF INJURY Y (S�r yt' farm. street. factory
<br />26g. LOCATION STREET OR R.F.D, NO. CITY OR TOWN = ..STATE
<br />❑ Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH (Mo.. Day. Yr.) I
<br />28a. DATE SIGNED /Mo.. Day. Yr.)
<br />28b. TIME OF DEATH .
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<br />27b. DATE SIGNE D (MO.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />. 10 M
<br />6
<br />27d. To the best of my knowledge eel occurred at t e, dal a la and due to the
<br />28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />causels) staled.
<br />Me time, date and place and due to the cause(s) stated.
<br />(S' nature and Tidal ►
<br />(Si nature and Title ) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO F] UNKNOWN
<br />❑ YES NO
<br />0-YES _, NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type or Print)
<br />David R. Colan M.D. 729 N. Custer, Grand Island, NE. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />FOR VITAL STATISTICS USE ONLY
<br />Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV...........................
<br />NSC...................................................................................:....................................................................................................... ............................... .........................Census Tract No.
<br />Work...................................................................................................................
<br />U C................ ....................................................................................................................................................................................................................... ........................................................
<br />Reject ................................................................................................. ................ ............................... . .
<br />...... ...............................
<br />4 Printed with soy Ink on recycled paper
<br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE
<br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA.
<br />�ER-GfEDDES_OUNEMI HOME BU
<br />GENERAL NOTARY-State of Nebraska
<br />III RAYMOND A. OSEKA
<br />My Comm. Exp. Nov. 27, 2004
<br />,Lot One Hundred 'Ninety Two (192), in West Lawn, an Addition to the City of
<br />Grand Island, Hall County, Nebraska.
<br />
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