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Rev. 1/94 STATE OF NEBRASKA - DEPARTMENT OF HEALTH 1 <br />BUREAU OF VITAL STATISTICS <br />200311537 CERTIFICATE OF DEATH <br />y <br />J <br />C <br />rn O <br />O <br />U <br />� c <br />7 <br />O <br />U <br />cx O <br />w <br />N <br />H m <br />a; <br />w <br />t� U <br />z <br />W E <br />W <br />0 d <br />LU <br />U 2 <br />W of <br />0 L <br />LL O <br />O� <br />W ro <br />O <br />Q <br />Z LL <br />M <br />co <br />=ENT FIRST MIDDLE LAST <br />2. SEX 3. DATE OF DEATH Month Day Year) <br />James Buck <br />Male February 5, 1995 <br />4. CITY AND STATE OF BIRTH itlnol in US.A. name country/ 5a. AGE last Binhday UNDER 1 YEAR <br />UNDER t DAY 6 DATE OF BIRTH ,Month. Day. Yearl <br />Lincoln, Nebraska (Yrs,L, 7 Sb MOS i DAYS <br />/ <br />5c, HOURS MIN$ 1917 <br />November 21, <br />261 PLACE OF. INJURY - At home. farm. street. factory <br />o ice building. etc At <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />yes No ❑ <br />506 -12 -6555 <br />HOSPITAL: Inpatient OTHER Nursing Horne <br />- - -- - -- <br />❑ ER Outpatient ❑ Residence <br />fib FACILITY - Name /p not rnshlueon, give streer and oumberl <br />• <br />St. Francis Skilled Care <br />❑ 0OA ❑ 0lheriSpec,ty,. <br />8c CITY TOWN OR LOCATION OF DEATH <br />8d INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />Grand Island, Nebraska <br />Yes ® No ❑ <br />Hall <br />78c. PRONOUNCED DEAD /Mo.. Day Yr I <br />9a. RESIDENCE -STATE <br />9b COUNTY <br />. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Includng Lp Codey, <br />9e INSIDE CITY LIMITS <br />M <br />o <br />70TY <br />o O 1 <br />- - -- - <br />2Be. On the basis of e.ani -hon and or invasllgation. in my opinion death occurred at <br />the time. data and place and due to the cause(s) stated. <br />Nebraska <br />Hall <br />and Island <br />1417 Stagecoach Rd <br />Y., [N No El <br />30.D WAS CONSENT GRANTED' <br />10. RACE - (a g.. While. Black. American Indian <br />(Specify) <br />11. ANCESTRY le 9 Italian, Mexican. German, elcl <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE of wif& . give maiden name) <br />Dr. John J. Cannella 729 North Custer Grand Island, Nebraska 68803 <br />etc I <br />White <br />ISpeciy) <br />German- French <br />XJ <br />NEVER DIVORCED <br />MARRI <br />Anita Bernice Carlson <br />tea. USUAL OCCUPATION /Gve kind of wak done during most <br />M working life, even d retrredl <br />tab KWD OF BUSINESS INDUSTRY <br />A <br />15. EDUCATION [Specify only highest grade completed) <br />Chairman of The Board <br />H (� e F ea era 1 Sav i n g <br />& Loan Assocla_1: <br />ElPin <br />ry� r Secondary I0 121 4 College I1 4c, 5.1 <br />1L <br />e <br />16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME <br />117 <br />Oren A. Beltzer Nellie - SchrePh <br />18. <br />WAS DECEASED EVER IN U.S. ARMED FORCES7 9a.INFORMANT -NAME - <br />(Yes . no. or unk.l III yes we war and dates of services) <br />W Iy/12 -17- 42/2 -20 -46 [Anita <br />Yes Bernice Beltzer <br />_ <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F D NO., CITY OR TOWN. STATE. ZIP) - <br />d and Island Nebraska 68801 <br />20. =FGNATU S <br />•' ' <br />METHODOF DISPOSITION <br />21b. DATE <br />_ <br />21c CEMETERY OR CREMA tORV NAME <br />//21a. <br />Y` /��� <br />/ <br />❑Boreal ❑Removal <br />eb. 8, 1995 <br />ebraska Anatomical Board <br />22a. FUNERAL HOME NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />_ Butler-Geddes <br />❑ Cremation © Dpnaton <br />Omaha, Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D NO CITY OR TOWN. STATE. ZIP) -- <br />1123 West 2nd Street, Grand Island, Nebraska 68801 <br />23 IMMFMATF r'AI ICF <br />,,,n inter "ai le-PI, onset I'll pram <br />PART I <br />(a) <br />�t UE �j f a5 S <br />DUE TO. OR AS A G b NSE OVENCE OF - -- -- <br />IN <br />DUE TO. <br />RM <br />t Inler�al between onset an0 nedtn <br />I <br />Interval between. onset ano -,Ie ti, <br />I <br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 2a AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PART <br />II PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER' <br />(Ages 10 -541 Yes No Yes No yes No <br />26a 26b DATE OF INJURY /MO.. Day. Yr.1 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED <br />El Accident [J Undeemmed <br />M <br />Suicide El Pending <br />26e INJURY AT WORK <br />261 PLACE OF. INJURY - At home. farm. street. factory <br />o ice building. etc At <br />26g. LOCATION STREET OR R.F D. NO. CITY OR TOWN STATE <br />Homicide Inveshgation <br />El❑ <br />yes No ❑ <br />27a DATE OF DEATH /Mo. Day YrI <br />28a. DATE SIGNED /Mo Day. Yr1 <br />28b TIME OF DEATH <br />M <br />`i <br />a > <br />27D. DATE SIGNED /MO.. Day Yrl <br />27C. TIME OF DEATH <br />78c. PRONOUNCED DEAD /Mo.. Day Yr I <br />__ <br />28d. PRONOUNCED DEAD ("­l <br />M <br />Q z <br />z <br />M <br />o <br />$ o <br />o .0 <br />27d. To the bait of my wedge. oe @ @@ urre�rRt +e. dat ce and,,,,dddd re. ro the <br />Cayselsl staled. \ \ \ <br />\` ^ <br />- - -- - <br />2Be. On the basis of e.ani -hon and or invasllgation. in my opinion death occurred at <br />the time. data and place and due to the cause(s) stated. <br />�\ ` <br />(Signature and Title(► ^1 �/\ \� W <br />IS, nature and Tiae ► <br />29. 010 TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ 610 <br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.D WAS CONSENT GRANTED' <br />YES <br />1:1 UNKNOWN. <br />❑ YES "e-_NO <br />❑ YES IJV NO <br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or prinll -- <br />Dr. John J. Cannella 729 North Custer Grand Island, Nebraska 68803 <br />37a. REGISTRAR <br />3211 . DATE FILED BY REGISTRAR /Mo. Day _ Yr) _ <br />FOR VITAL STATISTICS USE ONLY <br />UC <br />Reject ...... <br />0 Pnnt.d with -y Ink - r.orol.d paper 6 <br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE <br />FILED WITH THE BUREAU OF VITAL ISTICS If' T,INCOLN, NEBRASKA. <br />APFEL- BUTLER -C ODES FUNERAL HOME <br />jj GENERAL NOTARY-State Of Nebraska <br />RAYMOND A. OSEM <br />my Comm. Em. par. 27, 2004 <br />