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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYS7FM, 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 STATlSTlC$ SECl1t'-it~,_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'" ,.'," ' " ,4-'.o,~",'~:J>" ~:::'~,----:~,:~Z',-,:,~:,i~.,
<br />
<br />DA TE OF ISSUANCE ~- ~ -...,- - -, ,-.
<br />
<br />~.~:;KA 200 GOO 282 HEALTH:.,-=a~ef;~
<br />
<br />.'.--." ~ ~
<br />.~- , ."~~'.', .., .~- --
<br />STATE OF NEBRASKA- DEPARTMENT OF REALlH AND HUMAN SERVICES F~Nf~;~~';~=-~
<br />VITAL STATISTICS-"" -;c, ,_.."--'~c,,,
<br />CERTIFICATE OF DEA TH~~:i-~~~~,~i~3
<br />
<br />09198
<br />
<br />,. DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />LAST
<br />
<br />
<br />MIDDLE
<br />
<br />2. SEX
<br />
<br />Paul
<br />
<br />Johrlson
<br />
<br />Male
<br />
<br />2003
<br />
<br />Ganson
<br />
<br />4. CITY AND STATE OF BIRTH (If not in U,S.A.. name country)
<br />
<br />Sa. AGE. last Birthday UNDER 1 YEAR
<br />IY".I 5b. MOS. DAYS
<br />85
<br />
<br />UNDER 1 DAY
<br />50. HOURS' MINS.
<br />
<br />1918
<br />
<br />6. DATE OF BIRTH iMonth. Day Year!
<br />
<br />Mason Ci t , Nebraska
<br />7. SOCIAL SECURTlV NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />
<br />507-12-1417
<br />8~. FACII.ITV - Name
<br />
<br />HOSPITAL IKJ
<br />
<br />o
<br />o
<br />
<br />Inpatient OTHER: 0 NurSing Home
<br />ER Outpatient 0 ReSIdence
<br />DOA 0 Other {Sp8clflil
<br />
<br />(If not instifutiDfJ, give street ana number)
<br />
<br />St. Francis Medical Center
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />Grand Island
<br />9.. RESIDENCE. STATE
<br />
<br />
<br />Gilman
<br />
<br />8d. INSIDE CITY l.IMITS
<br />
<br />
<br />9d. STREET AND NUMBER (InCluding Zip Cod_!
<br />
<br />ge. INSIDE CllV LIMITS
<br />
<br />68883 Y.. IX] No 0
<br />
<br />13. NAME OF SPOUSE {If Wife. gIVe maiclen name}
<br />
<br />Nebraska
<br />1 Q. RACE - (e.g.; White. BlaCk. American Indian. 11, ANCESTRY le.g.. Italian. Mexican, German, ete)
<br />elc.jISpoc't/l ISpocl~
<br />Wni te .En
<br />
<br />14a. USUAL OCCUPATION (Give kind 01 work don. during most
<br />(J( working life, even if rstirsd)
<br />Grocer
<br />
<br />Thelma Boeka
<br />
<br />15. EDUCATION (Specify only highesl g'ade compleledl
<br />Elementary Or Secondary (0-12) College /1 -4 Or 5"'1
<br />4
<br />FIRST MIDDLE MAIDEN SURNAME
<br />
<br />16. FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />Fred H.
<br />18. WAS DECEASED EV~R IN u.S. ARMED FORCES?
<br />{Yes, no, or Urik,j (If yes. give war and dates of services)
<br />Yes 8-12-42 to 12-29-45
<br />19b, INFORMANT MAII.ING ADOR~SS ISTREET OR HF.D. NO.. CITY OR TOWN. STATE. ZIPj
<br />
<br />Bertha
<br />
<br />Lee
<br />
<br />409 East 11 th street
<br />20. EMBAlM~R - SIGNATURE & l.ICENSE NO.
<br />
<br />Wood River NE
<br />
<br />68883
<br />
<br />21a. METHOD OF DISPOSITIDN 21 b. DATE
<br />
<br />210. C~METERY ORCREMATOAY NAME
<br />
<br />Not Embalmed
<br />22a. FUNERAL HOMe - NAMe
<br />
<br />D Burial D Removal 8/15/03 Cent. Nebr. Crem. Serv .
<br />21d. CEMETERY OR CREMATORY 1.0CATlON CITY OR TOWN STATE
<br />
<br />Apfel Funeral Home g C,.m...,., 0 Donallon
<br />22b. FUNERAl. HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />Gibbon, NE
<br />
<br />411 West 11th st.' P.o. Box 126
<br />
<br />/It. ~ AI "N- b ,- '1
<br />~ UI
<br />DUE TO. OR AS A CONSEOUENCE OF'
<br />~ ff./f
<br />
<br />Wood River
<br />
<br />NE
<br />
<br />68883
<br />
<br />I Interval between onset and de<;lth
<br />
<br />: .:I: I?'\*,ecl;<<fc
<br />
<br />I Imerval between onset and death
<br />
<br />: 2 q t,,"i.-.,I'f
<br />I
<br />I Interval between onsel and deatn
<br />I
<br />I
<br />,.
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />
<br />23. IMMEDIATE CAUSE
<br />PART
<br />I
<br />
<br />IENTER ONI. Y ONE CAUSe PER LINE FOR lal. Ibj. ANDlcll
<br />
<br />.Q.rrpt;.<f
<br />
<br />Ibl
<br />DuE TO. OR AS A CONSEOUENCE OF.
<br />
<br />~.
<br />
<br />(el
<br />OTHE:A SIGNIFICANT CONDITIONS. Conditions contributing 101M death but not related
<br />PART ,) _. { I
<br />II ~ fb..' CAr-e
<br />
<br />26a.
<br />0 Accident 0 Undetermined
<br />0 SuiCide 0 Pending
<br />0 Homicide Investigation
<br />
<br />
<br />2Gb. DATE OF INJURY (Mo.. Day. Yr.) 28c. HOUR OF INJURY
<br />
<br />STR~ET OR R.F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />?6g. lOCATION
<br />
<br />~~
<br />0;>->-
<br />fib'
<br />u ~o
<br />]!'j1
<br />o .
<br />~::;;
<br />
<br />26e. INJURY AT WORK
<br />Yes 0 No 0
<br />27a. DATE OF DEATH {Mo.. Day. Yr.}
<br />f "t{-. 0 ~
<br />
<br />s"'"
<br />j~~
<br />~iEt:>-
<br />8~~g
<br />~L
<br />8 "
<br />
<br />26Et, On the basIs of examination and'or investigation, in my opinion death occurred at
<br />tne time. date and place and due to the cause(sl stated.
<br />
<br />28a. DATE SIGNED (Mo.. Day. Yf.)
<br />
<br />28b TIME OF DEATH
<br />
<br />
<br />260. PRONOUNCeD DEAD IMo.. Day, Ye!
<br />
<br />2Bd. PRONOUNCED DEAD {Ho,,"
<br />
<br />27b. DATe SIGNED {Mo.. Day. Yr.!
<br />
<br />.r~IS'o3
<br />
<br />M
<br />
<br />SO.b WAS CONSENT GRANTED?
<br />D YES
<br />
<br />~NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY} iTy". or Prinr)
<br />
<br />"
<br />
<br />Gary L. Sett'e
<br />32a. REGISTRAR
<br />
<br />400 Grand Island NE
<br />32b. DATE FII.ED ay REGISTRAR IMo.. Day y,}
<br />AUG 2 0 2003
<br />
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<br />
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<br />
<br />6880.
<br />
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