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<br /> ;0 Q .5.r c <br /> f1 m .--..:> <br /> ." ~ (")(.fl <br /> c: m en <.::::::> <br /> () :c ~ o-t <br /> :0- () z "" ~~ C"_ cJ> <br /> 6; ::I: n 0 :::0 %-1 <br /> rn )> ~ Z -tm <br />N () (I') ~ -<0 <br />S (n "" :x: ~ .- 0"Tl <br />S 5 JI ..." .- "Tl :z: <br />(j) 0 r :r: m <br />S 0 <br />S m -0 )> en <br />eN m ::3 r- ::0 <br /> 0 r l> <br />s (/) (f) <br />N C.;) ;::0;: <br /> :> <br /> 11'II8 -........ <br /> ..r:; ... <br /> .. <br />"----. -..- .-...-"... .~_.._..,.~ <br /> <br /> <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPARTMENT OF HEAL TH, <br />IT CERTIFIES THE BELOW TO BE A TRUE COpy OF AN ORIGINAL RECORD ON FIL~WjJf!~STATE <br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STA TIS TICS, WHICH IS THE LEJ1~LJ!EPOSitiifj"'-'KOR <br /> <br /> <br />:::::::~CE 200600302 ~~!~ <br /> <br />NOV 29 1995 AssiS1AN1.'STATEREGISTRA~R~ <br />, NEBRASKA'--iJEPARTM'ENT OF IiEAL rHil <br />W,/,5.,ro B1cd-3 er~itd~rt~-{~.td!J~H~ +-0 <br />STATE OF NEBRASKA - DEPARTMENT OF'~. ...!i!. ""-"'W.,-.3. M ./7 \ r~ Ir' <br />BUREAU OF VITAL STATISTICS."'':''..,', .-~ - . " 17"' \ V 1.../, I <br />CERTIFICATE OF DEATH ".-.. <br /> <br />LINCOLN, NEBRASKA <br /> <br />1. DECW~NT ' NAME <br /> <br />MIDDL~ <br /> <br />LAST <br /> <br />~ s~x <br /> <br />FIRST <br /> <br />3. DATE OF D~TH (Mon#>. Dav Yea,) <br /> <br />Philip <br /> <br />Sheridan Hamm, Sr. Male 1995 <br />... AGE'lOoIlli"",,"v UNDER I VEAR UNDER 1 DAV 6. DAT~ Of BIRTH ,_. Doy. YoaN <br />(V".I 50. MOS OAYS 5<;. HOURS MINS <br />64 27 1 31 <br /> <br />4. CllY AND STATE OF BIRTH IN oot '" USA.. namII coonry/ <br /> <br />Sarver, Pennsylvania <br /> <br />7. SOCIAL SE UATIY NUMBER <br /> <br />80. PLACE Of DEATH <br /> <br />208 26 1701 <br /> <br />HOSPITAL' IKX ,- <br />DER~' <br />DDOA <br /> <br />OlHEA 0 NurSing Home <br /> <br />o ReSIOeI"1Ct! <br /> <br />o 011>o< 1$p<<.Iy, <br /> <br />III> FACILllY, N..... <br /> <br />INoot'_.fI""'__~_ <br /> <br />VA Medical Center, 2201 N. <br />lie. CITV. TOWN OR lOCATION Of DEATH <br /> <br />"Grand Island, Nebraska <br />9a RESIDENCE' STATE <br /> <br />Nebraska <br /> <br /> <br />Sd. INSIDE CITY UMlTS Ilo COUNTY OF OfATII <br /> <br />9<l STREET AND NUMBER {'''''''''''''Il?.p C_I <br /> <br />[Ie INSIDE CITY LIMITS <br /> <br />Yes ~ No 0 <br /> <br />10. RAC~ ,Ie.g., While. Bloel<. Amooc:an Incloan. <br />elClISI>e<olvI Wh i t e <br /> <br />ISQo<olv' <br />French, German <br />"a USUAL OCCUPATION IGwo ItJnd 01_ _ rUit>g __ .4b. KIND OF BUSINESS INDUSTRY <br /> <br />oIiP6ri~'Officer, Retired <br /> <br />Beverly Alice Doutt <br /> <br />15 E: OUCA nON [Specify only hlgtlest grade cornpleledl <br />Elementary or SecQndary (0-12) College 11-4 01 ~.l <br />12th <br /> <br />16 FATHER - NAME <br /> <br />MiDDlE <br /> <br />MIDDlE <br /> <br />MAIDEN SURNAME <br /> <br />FIRST <br /> <br />(Dec. ) Harry Elmer Cora <br />lB. WAS DECEASED EVER IN u.s ARMED FORCES? <br /> <br />?'es""""'-I .qrelnarrt~i~m'o - 7/31/7 Beverly A. Hamm <br />"Ib INFORMANT MAlUNG ADDRESS ISTREET OR RF 0 NO.. Cl1Y OR TOWN. STATE liP) <br /> <br />11. <br /> <br />McCreery <br /> <br />402 E. <br /> <br /> <br />21a UETliOllOF DISPOSITION ~lb, DATE <br /> <br />21c. CEMETERV OR CREMATORV NAME <br /> <br />~1lunAf 0-" Nov 6 1995 Greenwood Memorial Park <br />210. CEMETERYORCR~MAT()RY LOCATION CITY QR TOWN STATE <br /> <br />Dc-DIlonAt"" <br /> <br />.Lower Burrell Penns lvania <br /> <br />A fel Funeral Home <br />22b. FUNERAl HOME AODRESS fSTREET OR R.F.D. NO.. CllY OR TOWN. STATE, ZIl'I <br /> <br />Wood River <br />23. IMMEOII\.TE CAUSE <br />PART <br />I <br /> <br />Nebraska <br /> <br />68883-126 <br />(ENTER ONLY ONE CAUSE PER LINE. FOR 'al. Ibl. AND (ell <br /> <br />I Interval between on~ arid dedlh <br />.. ~~ I <br />: 10 Months <br /> <br />I Imer.....al between onset ana ~atti <br />I <br />I <br />I <br />I Interval between onsel and oeatn <br />I <br />I <br />I <br />25., WAS CA~,J: RI;FE~RED TO MEDICAL <br />EXAMINER OR CORONER' <br /> <br />la' Brain Tumor -unknown type <br />DUE TO. OR AS A CONSEOUENCE OF <br /> <br />Ibl <br />OOE TO. OR AS "COHSEOUENCEOF, <br /> <br />lei <br />OlMER SIGNIFICANT CONf.OTIONS ~ """"""*'lllo",._ "",...- <br />PART <br />II <br /> <br /> <br />26A.. <br /> <br />261>. DAlE Of INJURY lMo. Day. Y'I 2&. HOuR OF INJURV <br /> <br />o Acc<lool <br />o Suoc... <br />o -... <br /> <br />OU_- <br /> <br />OPend<ng <br /> <br />,- <br /> <br />Yeo D No 0 <br /> <br />M <br />2Ill. ~;&.~~~V iw:J/Yf' 'om>. ......laclory <br /> <br />STAn= <br /> <br />26j1. LOCATION <br /> <br />STREET OR RFD NO. <br /> <br />CITy OR TOWN <br /> <br />260. INJURY AT WORK <br /> <br />27. DATE Of DEATH IMo Day yo <br /> <br />28&. DA'l'E SIGNED l/.Ie Dav YrI <br /> <br />~III> TIME OF DEATH <br /> <br />.;,~ <br />I~ ~ <br />~it <br /> <br />" " <br /> <br />November 1. <br /> <br />;;~i <br />~illo <br />t~~~ <br />8~~~ <br />B~5 <br />"'15'-' <br />L> ~ <br /> <br />28e. On the basis of exammaoon and 'or ~tJon, in my opcnl(ln (Seam occurred at <br />.... 'me, dab> """ piao;. a""'ue 10 11>0 cau5elSI Slaled. <br /> <br />1995 <br /> <br /> <br /><!B< PRONOUNCED DEAD IMo. Day, v, I <br /> <br />2Sd. PRONOUNCED DEAD lHoIJ,' <br /> <br />P M <br /> <br />"""~lay <br /> <br />3O.b WAS CONSENT GRANTED' <br />o yES fXj NO <br /> <br />KlNO <br /> <br />(Type ar PMfJ <br /> <br />Charles N. Lye, M.D., VA Medical Center. 2201 N. <br /> <br />Broadwell. Grand Island, NE 68803 <br /> <br />rATE '~ED BNOvRAR 61995 <br /> <br />~a. REGtS1AAR <br /> <br /> <br />y <br /> <br />~ <br />~s. <br />O?: <br /> <br />~I <br /> <br />02 <br />~O <br /> <br />G':"- <br />0~ <br /> <br />M <br /> <br />M <br />