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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />I. [)ECm~NT-:-iiilME
<br />
<br />----~-.-_.~r____-.---
<br />
<br />LAST
<br />
<br />? SEX
<br />
<br />,J. OA 1 [ Or- DEA TH {Month D(JI' YP.Rf'
<br />February 2. 1995
<br />
<br />Fred
<br />
<br />Kyser
<br />
<br />Male
<br />
<br />R.
<br />
<br />~. CITy AN"'O'STA1E: Of= BIRTH (lfnofhUSA"nBl1JfJCOU""YI
<br />
<br />
<br />6. DAlE O~ BIRTH (AAofI"", Day r~R'J
<br />October 15. 1927
<br />
<br />50. AG~
<br />IV,. I
<br />
<br />UNDER I pAY
<br /><;c. HOURS' ",INS
<br />
<br />Mullen. Nebraska
<br />1. SOCIAL SECURTlY NuMBER
<br />
<br />67
<br />
<br />T
<br />
<br />
<br />led INSIDE CIlY L1MIlS'
<br />
<br />~ Yes~NnD
<br />
<br />90. CIlY, TOWN OR LOCATION
<br />
<br />9~ INSIOF r;l'h' 11~1 f ~
<br />
<br />o
<br />[Xl
<br />o
<br />
<br />.
<br />
<br />565-40-8766
<br />
<br />Inpatlel1t
<br />
<br />OTHER. 0 Nl,Jf!'itnq Horne
<br />
<br />o R@!';ldp.11ce
<br />
<br />o Olhf'!r (.~ppl.Ifrl ,".~"_".~,,.~.
<br />
<br />HOSPITAL
<br />
<br />
<br />E::I=I Outpatienl
<br />
<br />(If nol /nsrituffon, gIve streel BfKf number}
<br />Francis Medical Center
<br />
<br />[){)A
<br />
<br />
<br />MIDDI.E
<br />
<br />MA,m:N SURNAMI.
<br />
<br />Grand Island
<br />
<br />90. RESIDENCE :'S1 A'I ~
<br />Nebraska
<br />
<br />
<br />Virginia A. Paxton
<br />
<br />9d S1 RFET AND NUMBER (lnc/~~fj;;g>ip Corlel
<br />North Rd.68803
<br />
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<br />
<br />f 1. ANCESlRY (e,g.. Its"an. Melfican. German. 8tel
<br />IS""o,ly,
<br />American
<br />
<br />10. RACE -Ie,g.. While FJlack, ArnariC8!1lndian
<br />"""IIS""oly)
<br />White
<br />'4., USUAl. OCCUP^ lION (Gille kind ot wo/..: dcJil8 during most
<br />(.11 wnrll1fl9 fifrJ. even If rerit8f.11
<br />Laborer
<br />
<br />13, NAME O~ $POLJSf (" wife ,Qive m~lf1pn namp!
<br />
<br />
<br />Farm Implements
<br />
<br />15. EDUCATION ISpoo,tyonlyhlgheslgrodooompleleO) ___ ,
<br />EJemenUtfyorrarVIO-121: ~!.11,,411~~.'1
<br />
<br />FIRst
<br />
<br />MlnOIF
<br />
<br />I.A5T
<br />
<br />17 MOTHE~
<br />
<br />Grace
<br />
<br />R.
<br />
<br />Marsh
<br />
<br />Richard
<br />
<br />H.
<br />
<br />North Rd., Grand Island, Nebraska 68803
<br />
<br />OQ ~M -"GNAT . HI:EN:::~ ~ !L //1/ 2~M:::loOf~:~~::al~;,:~: _~_' ~~_~~.~~l~l~~~~;:~_Oi~:~~~:-~~-E"~~sW~~ig~
<br />
<br />22. fUNfRALHOM A~ ~ 2.d CEMETERYOHCHEMAIORYLOCAIION ClfYORfOWN ',,"If
<br />Livingston-Sond~ann F.R. []C,"mOIl." 000"""" Gibbon. Nebraska
<br />
<br />22b:F"UNERAL'HOM"i'ADDRESS ISTREET OR A.F.D. NO.. ClfYOR TOWN. SlATE,Zli1 - ---~---~- ..-.-..-.-.. - - ---. __.._.,_m
<br />505 West Koenig. Grand Island. Nebraska 68801
<br />
<br />,nt(tt'v~i"bet;;en-;~;I:iwt (I"ill!
<br />
<br />~MJ. Ji ,\,~J:~_
<br />'k-"~J;;.'~;,(
<br />
<br />fn1et'la~~ll O~~~;I~I~:f~ "'.,d'
<br />
<br />23 'MME~TE CAliSE
<br />PART . I
<br />
<br />I la, f1'f"/A,iu."f
<br />
<br />--OU~m:Oii AS A CONSEOUE'/5EOF
<br />
<br />(bl C~tOY,I'L 06s'hv>J,~
<br />-------outiO,<JR AS A CONSHlUEN(;E &--:--~---
<br />
<br />A r ~+ IENTER ONLY ONE CAliSE PER LINE ~:~,~a.I,I~:_~:~~_.
<br />
<br />I
<br />I
<br />I
<br />:'Y
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />25. WASCAS[ REFEnnffl Ii) M~'Hlf,,'I,:
<br />E)(AMINE.~ OR COF~O"'H..H
<br />YOS__D__________N" W
<br />
<br />n~.l~~+__~~~ ~_
<br />
<br />"1
<br />
<br />101
<br />;;:;r OTHEn .SiGNIFICAN"t r.ONOIfIONS - Conditions r.onhibUling to the deBth but not ,elSlled
<br />
<br />II
<br />
<br />
<br />>I.
<br />
<br />"60, '-[26b DATE OF INJURY
<br />[1 ACCident [J LJndf!lf!rmlrlerl
<br />[] '"""1<18 LJ P'O<l!Ilg _ INJIJI'lY AT 'MJR!I:
<br />o Homicide 'nve~T1IgaflQn Vas 0 No 0
<br />210 DATE OF DEATH IMo. Day. Yr)
<br />
<br />26<. HOUR OF INJURY
<br />
<br />.. . sTRirToiiR-:F~o:NO----------c,TV-iiR TOWN---
<br />
<br />:>eg. LOCATION
<br />
<br />'" ~ , [
<br />
<br />260 nATE SIGNFD 1M(> DR' yo I: TIME Of DEATH' ---
<br />
<br />
<br />260 PRONO~NC:~ _D:~:_~MO DoY. Yr '__1: PRONOlINCED DEAD I""
<br />
<br />
<br />286. On the basis of 6)1lJrnina1ion and/or InvestigRtiOn. in my opinion death I)(:(':m'~ i'"
<br />Ihe ';"'.. dote om ploo. a"" due 10 Ihe co"""'., stated,
<br />
<br />M
<br />
<br />I. cJ"cJA
<br />
<br />27b DATi SIGNED (M<>. 0.., y,!
<br />
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<br />
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<br />IF'
<br />
<br />M
<br />
<br />270 TIME OF DEATH
<br />
<br />
<br />M
<br />
<br />30b WAS CONSENT GRANTED?
<br />o YES
<br />
<br />iKl NO
<br />
<br />o NO
<br />
<br />
<br />c.
<br />
<br />St. Franc e ca enter
<br />
<br />rJ.. . cfJ. 2620 W. Faidley. Grand Island. NE 68803
<br />J2b DAlE FILED BY AEGISlRAR lMo.. Osy, Yr.}
<br />
<br />FOR VITAL STATISTICS USE ONLY
<br />
<br />.D ................................E... ,........................,Part II......................TMV ___......
<br />
<br />______,.....".__.. ______.........._........... ........................................................___.._... Census T r :wt Nn
<br />
<br />Place .................,.....A ...,..............____..........8 .....__...._,.....,............,C ,.....,........
<br />
<br />NSC,............,."."'...._....._......_............,............................................,_,..............,.........,..
<br />
<br />Work.............
<br />
<br />UC,.....__.........__.._..___._.....,.,................,..........................,.....................................................,.....,............"..............,.,.
<br />
<br />Reject ........._..._...._.......,............".."..........................-...:.................................... ....... ......, ,.-.............,....- ..".,-.-....,........................."...
<br />....,...'......................'...................
<br />
<br />o Pt1n,.., wtift ..." he .;n rwcycMd ........ ,
<br />
<br />, hereby certify this to be a true and correct copy of the original filed with the
<br />State of Nebraska :i2 /j) ,
<br />~"-~,~, by _ . '~
<br />Signed in my ~.iS ~ ~_19:lS-
<br />~ Nctary PublIC
<br />
<br />r'-1\'GENEAAl NOTARV-State of ~ebraska
<br />~ [,iil DANiEl D N~fV\N~
<br />.~':..-~~~~~f:1L~U!~'"L~2~_~;~._.;.
<br />
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