|
<br />u:l
<br />~
<br />M
<br />~
<br />~
<br />u:l
<br /><:;)
<br />o
<br />~
<br />
<br />.
<br />
<br />Qj
<br />c
<br />e
<br />o
<br />o
<br />>-
<br />E
<br />::J
<br />o
<br />o
<br />(;
<br />(jj
<br />c
<br />.e
<br /><1l
<br />x
<br />CD
<br />"iii
<br />o
<br />'6
<br />CD
<br />....E
<br />Z c-
<br />W<1l
<br />c.o
<br />W.-
<br />O~
<br />w.r:.
<br />co.
<br />Ll.>-
<br />O~
<br />W Ul ........................
<br />::::z:::J .
<br />
<br />~& ~:::::::::::::::::::::::.
<br />o
<br />
<br />~C......................
<br />::J
<br />(/) ...... ..................
<br />
<br />0...,....................
<br />i=
<br />(/) .. ......... .............
<br />i=
<br /><C ..... ..... ..............
<br />t-
<br />(/)
<br />...JD.....................
<br /><C
<br />t- .......................,
<br />
<br />:> .......................
<br />II:
<br />a.......................
<br />Ll.
<br />
<br />to.. I Io...-l.....,....,. .. ....~, .
<br />INK
<br />SEE INSTRUCTION
<br />MANUAL
<br />
<br />Place............
<br />
<br />NSC....... ...........
<br />
<br />Work...............
<br />
<br />UC...............,
<br />
<br />Reject..........,... .
<br />
<br />A...................,.
<br />
<br />B.....................
<br />
<br />~
<br />
<br />E..,...................
<br />
<br />Part II
<br />
<br />TMV..................
<br />
<br />Census Tract No.
<br />
<br />Fle-v,3"'89
<br />
<br />aun..,..,,, ur 1111 AI- .,..M11~IZ\.o-O;'
<br />
<br />CERTIFICATE OF DEATH
<br />
<br />1. DEC WENT - NAM E
<br />
<br />FIRST
<br />
<br />M I DOLE
<br />
<br />3, DATE OF DEATH (Month. Day, Year!
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />Della
<br />
<br />Agnes Nett1eingham
<br />
<br />Sa. AGE . L... B<rthoay N 1 A
<br />IY'",I Sb. >dOS.' DAYS
<br />101 :
<br />
<br />Female
<br />
<br />June 190, 1990
<br />6. DATE OF BIRTH (Morrill, Day, Year!
<br />
<br />Milford, Nebraska
<br />
<br />
<br />4, CITY AN 0 ST ATE OF B~RTH W no! in USA, na",.. <ounlTy!
<br />
<br />Y
<br />Sc, HOURSI MINS.
<br />I
<br />I
<br />
<br />Jan. 1, 1889
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />HOS PIT AL: 0 Inl>O-,e", 0 ERIOulpa'''''' 0 DDA
<br />OTH ER: M Nu,s;~ Home 0 Residence 0 Ott>e< (Specily)
<br />Be. CITY, TOWN OR LOCATION OF DEATH
<br />
<br />505-22-6539
<br />
<br />
<br />Bb. F AC IUTY . Name
<br />
<br />(If not frt.5tilutiorJ, give Slreet and numberj
<br />
<br />Lakeview Nursing Home
<br />
<br />Grand Island
<br />
<br />9a. RESIDENCE . STATE
<br />
<br />
<br />I"" r
<br />I Co~iege [1.4 or 5"'" ~
<br />I
<br />I
<br />M I DDUE LAST
<br />
<br />i1c. CITY. TOWN OR LOCA TjOO
<br />
<br />!!e. INSLDE CITY LIMITS
<br />(Specdy Yes or M>!
<br />Yes
<br />
<br />Nebraska
<br />
<br />10. FtACE . (e.;.... White. Black. Ameiican I nd~a.n,
<br />""'JJ.SfHIC'fy)
<br />wnlte
<br />
<br />H. ANCESTRY (e.g.,<<aiian. Mexican, German:, etc.J
<br />(Specify! .
<br />AmerIcan
<br />
<br />, 4a,. USUAL OCCUPATION (Give kind 01 worlr done during most
<br />at wort!f'g Me, even if felired)
<br />Clerk
<br />
<br />14b_
<br />
<br />16. FATHER - NAME
<br />
<br />FIRST
<br />
<br />MJDDLE
<br />
<br />17. MOTHER. MAl DEN NAME
<br />
<br />FIRST
<br />
<br />Peter
<br />
<br />Emma Unzicker
<br />[STREET OR R.F,D. NO.. CITY OR T~~8B:r Z'PI
<br />
<br />Alvin Nettleingham-1915 W. Call e-Grand Island, NE
<br />20c, CEMETERY OR CREMATORY.. NAME 2Od, LOGA TlON CITY OR TOWN STATE
<br />
<br />1 S. WAS DECEASED EVER IN u.s. A AMED FORCES?
<br />lYes. 1'lO, or l.Jnk.] [~~es, giv! WaJ aM dales of serv~cesl
<br />No
<br />
<br />Blue Mound Cemete
<br />
<br />
<br />FUN ERAl HOME. NAME AND ADDRESS
<br />
<br />Milford, Nebraska
<br />[STREET OR RF .0. NO.. CITY OR TOWN, STATE, ZI PI
<br />
<br />1123 W. 2nd, Grand Island, NE6880l
<br />lnterYal between ol'\5el anod -death.
<br />
<br />a
<br />DUE TO. OR AS A CO OUENC E OF,
<br />
<br />e.~
<br />
<br />Interval between onsel and death
<br />
<br />b
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />interval betweei'l onset ancd dealh
<br />
<br /><
<br />OTH EA SIGNIFICANT CO N.OmONS . CoodmollS CQnEribulln-; to deaEh blll not related
<br />PART
<br />II
<br />
<br />2&0. INJURY AT WORK
<br />I'Specify Yes or No}
<br />
<br />
<br />STATE
<br />
<br />25. WAS CASE REFE RR ED TO MEDIC AL
<br />EXAMJN E R OR CORD NER?
<br />(Specily Ye. or M>!
<br />
<br />26.. ACCIDENT. SUiCIDE, HOMLC~DE, UNDET., 26b. DATE OF INJURY IMo..Day. Yr.) 260.
<br />OR PENDlNG INVESTIGA T'ON I Specify!
<br />
<br />STREET OR R, FD. NO.
<br />
<br />C~ TY OR TOWN
<br />
<br />27a. DATE OF DEATH
<br />
<br />2Ba OA TE. S.GN'ED lMo.., Day, Yr)
<br />
<br />28b. TIME OF DEATH
<br />
<br />June
<br />
<br />19,
<br />
<br />1990
<br />
<br />z>
<br />l;~*
<br />l?;:~>
<br />~..<~
<br />.:s:~5
<br />.!!,i!s
<br />~~8
<br />8"
<br />
<br />2'ae_ On me bastS 01 el[amlnatlon -and Crt ""'.'.eS'hgallOf'l. In m~ opmion dealh ace Urled at
<br />tI'Ie _time. dale aoo place ai't'd due toO the eause(s I slaEed_
<br />
<br />
<br />Day. Yr.)
<br />
<br />27<. TlME OF DEATH
<br />
<br />28c. PRONOU NC ED DEAD (Ilk>.. Day, Yr]
<br />
<br />2Bd. PRO NOUNCED 0 EAD {Hour}
<br />
<br />M
<br />
<br />JOb WAS CONSEkT GRANTED'
<br />
<br />:J YES
<br />
<br />:; NO
<br />
<br />G VES
<br />
<br />NO
<br />
<br />o UNKNOWN
<br />
<br />DYES
<br />
<br />.1. NAME AND ADDRESS OF CERTtFIER IPHYSICAN, CORONERS PHYSLCAN OR COUNTY AnORNEY~ {Type or P'mli
<br />
<br />Dr. J.J. Cannella M.D.
<br />32 a. REGI S TRAR
<br />
<br />729 No Custer,
<br />
<br />Grand Island, NE. 68803
<br />J2b. DATE f Il t::J B 'f f=lEGjSTR.AA iMo.. Day. Yr.}
<br />
<br />f:Ll
<br />~
<br />U
<br />H
<br />r..,
<br />H
<br />~
<br />f:Ll
<br />U
<br />::e
<br />~
<br />o
<br />...:l
<br />~
<br />tj~
<br />HUl
<br />g5~
<br />o:l
<br />f:Llf:Ll
<br />~Z
<br />
<br />~
<br />1:>3
<br />>i8
<br />~~
<br />~i
<br />::r::Ul
<br />o.u
<br />H
<br />E-iE-i
<br />U(I]
<br />~~
<br />f:Ll.:l:
<br />~~
<br />...:l
<br />~e:i
<br />H
<br />(1]:>
<br />H
<br />::eEL,
<br />E-i0
<br />~~
<br />::ef:Ll
<br />E-igj
<br />>io:l
<br />EL,
<br />Hf:Ll
<br />E-i::e
<br />&1E-i
<br />u::e
<br />>i~
<br />o:l3:
<br />gzo
<br />f:Llf:Ll
<br />::I:...:l
<br />H
<br />HJ::t.
<br />
<br />
<br />lei
<br />"~ ..
<br />,;}
<br />III
<br />I
<br />
<br />
|