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<br />Legal Description: Fractional Lot 3, in Fractional Block 125, in Union Pacific Railway
<br />Company's Second Addition, and its complement, to wit: Fractional Lot 3 in Fractional
<br />Block 2, in Russel Wheeler's Addition, both being additions to the City of Grand Island, c
<br />Hall County, Nebraska.
<br />WHEN THIS COPY CARMS TIE RAISED SEAL OF THE NEBRASKA HEALTH AA0 hq MAiU SZR hyt &
<br />SYSTEM, IT CVMWS THE BELOW TO BE A TRUE COPY OF THE ORMNA4I®ECIABL�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7/Sf& $
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />200310467
<br />AUG 1 2003 - — --
<br />LINCOLN, NEBRASKA HEALTH AAV SY
<br />STATE OF NEBRASKA —DEPARTMENT OF HEALTH (�
<br />BUREAU OF VITAL STATISTICS -- f j 5 9 3 R
<br />CERTIFICATE OF nFATN
<br />t. DECEDENT -NAME FIRST MIDDLE LAST I 2 SEX r.1, DATE OF DEATH (Mp11b, "(lay, yay)
<br />Vaden LaVon Loper Male j May 9,, 1990
<br />a CITY AND STATE OF BIRTH (MnorM U.S.A., name country) Sa AGE - Law B.nhoay 6 DATE OF BIRTH (Mona, Day Year,
<br />Yrs SD MOS
<br />DAYS 5c HOURy MMSS
<br />Hattiesburg, Mississippi �5
<br />t Sept. 20, 1924
<br />7. SOCYU- SECURITY NUMBER Be . PLACE OF DEATH YY
<br />HOSPITAL
<br />d MtpaWra Z ER pylpalyM :DOA
<br />428 -30 -2345
<br />OTHER 71 Nursing Hdno _ Howerice C dear
<br />6b FACILITY - Name (I7 nor -WAA dn. 9wm 1~ and number) Be. CITY, TOWN OR LOCATION OF DEATH 8a. WSIDE CItV LMirTS Be COUNTY OF DEATH
<br />St. Francis Medical Center Grand Island `�esYpa"°
<br />Hall
<br />1Y RESIDENCE -STATE
<br />9b. COUNTY
<br />9c CITY, TOWN OR LOCATION
<br />9d. STREET ANO NUMBER flndtranp Zip COON
<br />1M. INSIDE CITY Lam"
<br />Nebraska
<br />Hall
<br />Grand Island
<br />215 W. 8th
<br />YmAVAw
<br />10 RACE - le -g.•. Wive. rar_ Amve can Inman. t t. ANCESTRY (0.9- Jilalian, Mexican, amen, eu.i 72. MARRIEO,NEVER MARRIED. t3. NAME OF SPOUSE IN A, 9" i
<br />at I ISpacom Swirl%
<br />WIDOWED. pIVORGED (&"I
<br />Whig American D Married( Lois Sell
<br />lea. USUAL OCCWA7gN (G/W kntd d wax ddrM during mdar lab. KIND OF BUSINESS INDUSTH f IS SWIFATON
<br />of rrarNW)
<br />r. a S0rbrtdery M-12i� I Cone" (14 a
<br />=1
<br />Cus�n ���j3 Public Schools �U r
<br />16. FATHER • NAME FIRST MIDDLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST LrIDOLE LAST
<br />Edward Beaux Loper
<br />Margaret Mary Ann McDonald
<br />16. WAS DECEASED
<br />IYms. W, d una.
<br />Yes: 7-
<br />EVER IN U.S ARMED FORCE _
<br />M gas. wr and dales d sarvtcas!
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO.. C.TY OR TOWN, STATE DPI
<br />41 -21 -47
<br />ois Loper -215 W. 8th -Grand Island,NE. 68801
<br />20x. BURIAL, CrNtmaeort.Remcwal. 20b DATE 20c CEMETERY OR CREMATORY - NAME Md LOCATION CITY OR TOWN STATE
<br />Gone wn
<br />urial May 12, 1990 Oakwood Cemetery Weeping Water, NE.
<br />2I. E MER • SIGNATURE i L SE r10 �1 /l - FUNERAL HOME -NAME AND AuaRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, DPI
<br />'s[ V
<br />fel- Butler - Geddes 1123 W. 2nd, Grand Island, NE.6880
<br />4
<br />!!!ME .ATE CjA �7$,E (ENTER ONLY ONE CAUSE PER LINE FOR iaL (b), AND (cll Inlerva between onset and cheer
<br />PART
<br />I
<br />DUE TO, OR AS A CONSEuUENCE OF t,
<br />I Inyrva betats in orkea ofd tlaa6t
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Imsrva bowmen d»at and cheer
<br />I
<br />I
<br />PART OTHER SIGNIFICANT CONDITIONS - Condrlwns cdntrrbyan9 b dean but not ralaLO. RI 1F FEMALE. t HERE A 24 AUTOPSY W"r (� TO MECOCAL
<br />.
<br />..,,... » . .. Ge)ANLr Trio S° n�IFp+. ,IO/
<br />w. 7111
<br />- 'as C No -
<br />ZBa ACCIDENT. SUICIDE. HOMICIDE. UNDET, 26b. DATE OF INJURY (MO.Day. Yr) I26c. HOUR OF INJURY 26o DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Speedy/
<br />260. MNJURY AT WORK 261. PLACE OF INJURY - At home, farm, street. factory. 12% LOCATION STREET OR R.F.D CITY OR TOWN STATE
<br />( Speedy Y" or NO) off" building. elc. ( Speedy)
<br />27a. DATE OF DEATH (Mo, DAY. Yr1
<br />S -�t -9J
<br />284 DATE SIGNED (W, Day. Y l
<br />26b. TIME OF DEATH
<br />s
<br />I�
<br />27b. DATE SIGNED /Ab.. Day, n.) t27c TIME OF DEATH
<br />28c PRONOUNCED DEAD (aA7. wy, n(
<br />260 ogOlapllNCE0 DEAD MNpv)'
<br />.m.
<br />H;9
<br />s
<br />F�3:33
<br />291
<br />27d. To tM buret d my knowledge. Bean occurred a the ttme. date and dace and due to the
<br />cauamisl stable.
<br />2Be. On the basis a erarrwnaaon end d rnvesa9wan. A my oamw dean do&~ a
<br />�w1 .��
<br />�i 6
<br />the time. dab and place and due lo ne dausmisl SW W
<br />an0 TAaI1P /4✓
<br />IS natwe and TaNI
<br />2Ia DIO TOBACCO USE CONTRIBUTE TO THE DEATHS 30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDCRED7
<br />304 WAS CONSENT GRANTED'
<br />Z YES 7 NO V4)NKNOWN I G YES ANO
<br />L' YES ,:; NO
<br />31 NAIVE AND ADDRESS OF CERTIFIER IPHYMAN. CORONERS PHYSICAN OR COUNTY ATTORNEY) (Type or Prmr)
<br />Kathy Morse M.D. 729 N. Custer, Grand Island, NE. 68803
<br />i.
<br />32b DATE i1LEO BY REINSTRAR AID. 04 yr )
<br />Ad&"'-AZ 42XML -
<br />- 4f 1,4
<br />or ...... _. E�
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