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<br />... " <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRAS~ STATE <br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COpy <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEP~TMeNT hi HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEEbSITORY FO~ <br />VITAL RECORDS. "~ <br /> <br />~J ~';. <br /> <br />STANLEY S. C~OPE~, D]:RE~R <br />"',~ ' , ~~." , <br />2 0 0 6 0 2 3 2 2 BUREAU OF VITAL STA'l'IS~ICS <br /> <br />DATE OF ISSUANCE <br /> <br />t"'\ 4'"~) '"7""' " j <br />.R; 1 <br /> <br />~~r~q ! <br /> <br />LINCOLN, NEBRASKA <br /> <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br /> <br />,. DECEDENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />~. SEX <br /> <br />i 3. DATE OF OEATH (Mot/th.Oay. Year) <br /> <br />508-30-4610 <br /> <br /> <br />5a ~v~~, - LAst 8it1hday <br /> <br />''''61 <br /> <br /> <br />Jr. Male October 16 <br /> <br />'y 6 DATE OF BIRTH (Montf'l, Day, Y~at) <br />DAYS 5~, HOuFlS ~I",S <br /> <br />4. CITY AND ST A TE OF BIRTH <br />i <br />Broken Bow, <br /> <br />- 7. SOCIAL SECURITY NUMBER <br /> <br />Feb. 7, 1930 <br /> <br />: 8b "F'ACII..ITY - Name <br /> <br />(ff not institution. give 5"8" And numbsr) <br /> <br />HOSPIT&: X!lnpatter1t :J ER Outpatll;!!nt 0 DCA <br /> <br />OTHEA: 0 Nursing Home 0 R$$lclenC@ 0 Other {Specify! <br />8e CITY. TOWN OR LOCATION OF DEATH 8<l. INSIDE CITY LIMITS <br />(5wc1ty Ye5 Of No) <br />Grand Island Yes <br /> <br /> <br />90. CITY, TOWN OR LOCATION <br /> <br />9.. INSIDE CITY LIMITS <br />(SMelly Yos or Nol <br /> <br />Sheridan Ave. Yes <br /> <br />113. NAME OF SPOUSE (If Wife. give mall,en namB} <br />I <br /> <br />Ruth LaVon Goodman <br /> <br />V.A. Medical Center <br />9a. RESIDENCE. STATE <br /> <br />Nebraska <br /> <br /> <br />10. RACE - (e.g., White. Black, American Indian. 11. ANCESTRY Ie 9 ,lIahan, MeXlca", German, elc,} 0 12. MARRIED,NEVER MAt=!;RIEO, <br />.'e.1 IS_ily) ISPflCily) \) ~ WIDOWW DivORCED (SMelly! <br />White English/Irish/Danish Married <br /> <br />_ 14a. USUAL OCCUPATION (GIve kmd of work done durmg most () 14b. KIND OF BUSINESS INDUSTRY 1 <br />01 working life, even ,f rBI/red) rJ (- '.... \ n a. I') <br />~ Salesman 0' :.; Grain ,I. b if- <br /> <br />_ 15. FATHER _ NAME FIRST MIDDLE LAST 17. MOTHER. MAIDEN NAME <br />. <br /> <br />i George Franklin <br />-,.. WAS DECEASED EVER IN U.S ARMED FORCES? <br />{Yes. no, or un\(.} llf ';'88, give \IlI'$r aM oales of services) <br />Yes: A 3-5-47 3-4-50 <br /> <br />Elementary Or SeCOndary 10-121 <br />11 <br /> <br />College (1-4 Or 5+) <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2030. BURIAL. CrEl'mallon,Removal, <br />Donation <br />Burial <br /> <br />2Oll. DATE <br /> <br />Marie Johnson <br />[STREET OR R.F.D. NO.. CITY OR TOWN. STAT~. ZIPI <br /> <br />Ruth LaVon Dudle -2304 N. SheridanI~~~~~Gr~~d68803 <br />20e CEMETERY OR CREMATORY - NAME 20<1. LOCATION CITY OR TOWN <br /> <br /> <br />STATI; <br /> <br /> <br />A fel-Butler Gedd <br />(ENTER ONLY ONE CAUSE PER LINE FOR {al. {bl. AND {ell <br /> <br />19, 1991 <br />~/J7 <br /> <br />Westlawn Memorial Park <br />2~. FuNERAL HOME" NAME AND ADDRESS <br /> <br />Grand Island NE. <br />(STREET OR R.F.D. NO" CITY OR TOWN. STATE. ZIP) <br /> <br />21. <br /> <br /> <br />arcinoma with Metastasis <br /> <br />lliterval between onset and death <br /> <br />,) <br />'J <br />~ <br /> <br />lGi <br />DUE TO. OR AS A CONSEQUENCE OF <br /> <br />Interval between OnSef aM deatt1 <br /> <br />H rtension <br />25.. ACCIDENT. SUICIDE. HOMICIDE. UNDET" <br />OR PENDING INVESTIGATION (S_ily/ <br /> <br />OTHER SIGNIFICANT CONDITIONS - ConditiOnS contributing 10 death but not related <br />PART <br />II <br /> <br /> <br />~5b. DATE OF INJURY (Mo..D.y. Yr.) <br /> <br />PART III IF FEMALE, WAS T>1ERE A <br />PREGNANCY IN THE PAST 3 MONTHS' <br /> <br />Vel;> C No 0 <br />25d. DESCRIBE HOW INJURY OCCURRED <br /> <br /> <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />(Specify YC'$ or NO) <br /> <br />260 INJURY AT WORK <br />{Specify YI8& Or No} <br /> <br />STREET OR 1'1 F D NO <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />27.. DATE OF DEATH (Mo.. D.y. Yr.1 <br /> <br />26.. DATE SIGNED (Mo.. Day Yr.) <br /> <br />26b TIME OF DEATH <br /> <br /> <br />28e PRONOUNCED DEAD (Mo. OIly Y,.) <br /> <br />~1l<I. PRONOUNCED DEAD (Hour) <br /> <br />288, On Ihe DA$i5 01 examlnallOn :ilnd'or Inva!!;j:tlQa1lon. In my opinion dea.th occurred &1 <br />the lime, date Bnd place and due to tne caUSEtl$) staled. <br /> <br />300 WAS CONSENT GRANTED' <br /> <br />[j YES <br /> <br />~/ <br /> <br />31 <br /> <br />(Ty~ or Print! <br /> <br />! . __Hugh J. <br />- :J2.~ REGISTRAR' <br /> <br />2201 N. Broadwell Grand Island NE.6 <br />32b DATE FilED OifiR :f1991 <br /> <br />)OJd..- <br />