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<br />SlATE OF I-;rf.li'\ASKA - OEPA.'-' II.1ENT UF HEALTH AND Hl'~V.N SERVICES FINANCE AND SUPPORT
<br />CERT;t19l~TE OF D!;ATlL
<br />
<br />322508
<br />
<br />
<br />1 DEC;:DENTSN~"'E IFH'\'
<br />Elvera V.
<br />
<br />",.tdl..
<br />Johnson
<br />
<br />lB.I.
<br />
<br />2 SEX
<br />Female
<br />------ -.-- -.-l.-------n---n-.- -----.-- --- -.---
<br />., AGE.LA" B"n'~3Y I SbUfWE_R lYE~~~__~__UNDER 1 D~Y
<br />IY".) . "'OS DAVS ,.,OVRS: I,l'NS.
<br />
<br />Se".')
<br />
<br />1 DATE Of DE~TH ,1.10 Do,. Vr.)
<br />June 18. 2006
<br />
<br />. CITV ^ND 5mf. :)R 1[~R,lORV. OR fORE'GN COIJNl RV Of a,fnH
<br />
<br />6 DAre Of BIRTH i/,lo _ O.~, VI.)
<br />
<br />___A~~~d~~_ll_'___?p
<br />
<br />84
<br />
<br />May 17. 1922
<br />
<br />~
<br /><::>
<br />-~ <::>
<br />0')
<br /><::>>
<br />~
<br />00
<br />..J t-k
<br />ICJt
<br />
<br />7. SOCIA( Sf CURtlY N'-,"'BER eo PL~U: Of DCATl-I
<br />505--30-9694 i tmSPJl."L:
<br />n-llb~-F~C;lIT;NA!.lE (II r'OI 'nSlile"OO, g". 'Ir~;,~n(j-~:~-b-.'l n --- --1
<br />
<br />
<br />I_ ffiJJ\& n u e_!_J:~~~.P it a 1_____._______ ____.____ _.1
<br />k Cln OR10WN Of DEATH (Ir><lud. Zip C<:<!t)
<br />Omaha 68111
<br />
<br />;1. :"p Ileol
<br />
<br />O~ij: :J Nur..,og fk><n~UC Q ~-.p'ce F .c.i[1ly
<br />
<br />.J ER.'O'J~;:~:lenl
<br />
<br />:J 0/;<00."1'.110"'0
<br />
<br />:J(QI.
<br />
<br />~) O(hor :S;<<1fyI._.____n_ .
<br />
<br />-------'-M(~OONiY Of DEATH
<br />I
<br />Douglas
<br />
<br />-....-'"'T'""-----. . __n__________., -.--- ...---- .." '... ,.-., .....-.-. -.-.........--...---.
<br />; !lb COJNTY ] 9<. CIIY Oii TOWN
<br />1 Hall Doniphan
<br />9d. STREET AND NUMBER _n_______ ----- --------- ----------------- ---~ ------TS-----PT--N-6- 19f ZIP CO---------.---------rgg-,-~ Of- ---,S-
<br />..l~2__~_P_!'}_<:~~_.__~ane _ --.-----.-----------------r---------. ...... ________J.."A._ . L__~_~_~~________J~'~:~_~:_=~I~~
<br />
<br />10.. MARITAL STATUS AT TIME Of OEATH (l/ll,la<r~d 0 Ne,.r Ma"i.d 1'(lb, NAME OF SPOUSE (F~81, Middle.L.sl. S<rl'i.) M ",ilo, give maider> oB"'._
<br />
<br />o M"d,d. tu! ..paraled 0 Widc",.d 0 DivO<<e<l 0 Unlno""
<br />Stanley Johnson
<br />_~[~:';"~Atj;~ i~~;:__._ .__... -.--M0~~=:.' L~:_.--::'~~~~~ :].,2:.-~OT~~_~.~~M~_-.-(fi;.~I.-.-. Unk_~_o~;~.,_____.______~aid.n Su",o",.)
<br />
<br />13. EVER IN U.S_ ARi~[D fOfiCES? Give 6.1..0' \Crvico n Y". ~..INFOAI.1ANT-Ii~.ME
<br />(Yes."",orur>k") No I ley ;ohnson
<br />
<br />15 ;:::OfD~~~:~:::--I' ';EM~l;.R:~- _._ r _ -~<:&-~-----T6b-Lt?~- --------
<br />
<br />II Crer,.I,,,,, 0 [nlomhrnooj cMETERY. CREMATORY OR OTH, IX !.lION CITY /TOWN
<br />
<br />9.. RES~lENCE-STATE
<br />
<br />o Rornc'Ial
<br />
<br />
<br />West1awn-I-1illcrest lIemorial Park Omaha. Nebraska
<br />- - - - ---- - -------- -- -- - -, -- ----- - - -
<br />J lib Z'P C~d.
<br />
<br />Omaha. Nebraska 68106
<br />.:"~ '"'ill;::.,Pim~'~""-..,llm.'~'".o~'1'.,"{..-~"'-\.c''''''':<O'< '''",,*',. '~'.c''''--''''r:
<br />~r~~ ,"l~~)r}t,~ " -ft l~~:~ ~.~_~ ~~L.~'Wi~~.~\f.~~~{~~r.,.3>yi~ ~~:r.ij~\~<'I ')-),~'~~{~:~::\lli'~
<br />~1:!# _~ ^,,~YL -:..... ._~ . ~'; ~}'::'\~~.l$~~~~,,~,~_o<.~'.;..~l..,..jJ.. "'1N~..~}t~... ~.~~
<br />~.e: t\~~lh. 00 NOT enlN lerrruf\8:t eve!"l1.~, S,i,/()\ as C.,pd";ac a.fTe~ .t.Pi-'ffJX~MATE lN1 E:PYAL
<br />
<br />l'b RELATIONSHIP TO [llCLUfNT II
<br />Husband
<br />_____n___ .. ____.__--1
<br />Uk DAlE (1,10.. [l,~. y,-) I
<br />__!u~~__~}_ I 2006 .1
<br />SlATE
<br />
<br />-~
<br />
<br />17,,- fUNERAL HOME NAME AND MAlLIN(; ADDRESS (SHe!, C~y Of Town, S:"e)
<br />\~estlawn.-Hillcrest 5701 Center Steet
<br />.L;:~t:_~:~:J~&5~1tl~Jl~?~l~~~~~~~;;~~~t4}j:1~i~~w~~~[~~;~~1.':}Yi:~'::::':
<br />
<br />'! PART I. E!'\l~f {'Ie ~b.~_ir.LQ! ("I'.;;nt.~..,ji.s~;{!~s. irIjvrle.s, ClI C6l''{~rFC3fior,kfhal1iri..~.t~y ',.,~i;:'
<br />
<br />rc~.piralory alitS!, (){ ~fllricl1laf r~dh%liQr. w'it.~~JUt shl;,\\'ir~ t~j~ s.tklol{,._y. DO HOT AF)G.8(~ E. En~er {J(l'lyonf {'(H_~ or, I Ol)El ArX m\tiQr.al llnes If ~es~ary,
<br />
<br />::MmAeiAd/~(J/VlJl: ve, ~/.JudtLI fa cA tiU/ ell rt : ~~IIOd~m_
<br />_____._____.___________ _'__n___L_ . _____ ----------"2 __________-L_ b/}..11/;
<br />
<br />:::,;"ta<>_ r"',,1tiog DUE TO, OR AS A CONSEQUENCE Of; , . t :.e -1~ : ",~,:" ~-rl':Bm
<br />
<br />'"":::",":'~ _,,_ "11'fi~/lIl(oJ 0j!! ~Ivr/ f~f'_ (, -It) -!p---,
<br />~ne~:"L\::~: DUETO,2t;;EOiUrl7lfiJJ ell tlJJ to/tt<< . 6\~3~-lJh :
<br />~~:~~:=. :""OII-tJ:'d;~;;/;;tI-c--~-'-.. --- -- '~1!iffiJ-c-1
<br />-'''tj;;iieth';;tn;;;/i;.t.:.J6;;;11Jl~~;Z;Ti;Jt;'cL ,.::~::::=::::,~~
<br />__ _ ___________ ___. I ..~~~_~____?:_~O
<br />
<br />2'~.lf TRA.NSrcr,IATI(,~.NJURY 2k WAS AN AUTOPSV PERFCR!.lW'
<br />I :J Df',.,.'Oj...;'"Of -.. NO
<br />:J ~] YES 4
<br />I .. F'a.~~f\I8f i
<br />
<br />::J P[.,dc:5'f'~n r-'-... . -.-.- ..-----1
<br />D Silw;;ide :J C.{Ivk! hOl bf ":'bl~(minad ~ 21d. WLr~€. AU'TOPS'i FllmlNG$ AVA:'L~Bt.E TO !
<br />.:J Other tSpec,!v) I
<br />.~ Nc,l Pfc',J"1.ant, but ~''''~~:\.or'll ~3 <~'f$ 1(1 ~ y#ar befOfe d€alh I r CC>MPttTE CAl!Sf.' or OCl.,lH,?
<br />
<br />
<br />
<br />-::"~~;~":~;:;~~~l'~~~r=~~~d,.w,,=~":.~~~;,;~,.~~~~o_.___. ...._~
<br />""=;,,:;;:..;;';;.;,m,,___ :'~-T; ~- '," M0:~"'''"~; in ""T,.;TI.ii<ow."~ .. ..~
<br />n~ :~~~::'27sr.~-~ ll'ji~ ==,,~:~~::}=:>=~_
<br />! f r. :"h..::'":.:;:;:;:::;"_=.::':'';'.~ ~.~ lit '~~,::::=,-;':::'-=',,,:,,,;,:',~
<br />~~_ _ ~~R~~~t!a~~~~ ~-.- ~,-,<~~._.,~.,..,.>,.,~,-~ ,-,-~--~'''--
<br />~ DlD10a-'.CCOUSECQN1RIBUTUOTHHlEATH'I (.J.26' HASOR'3N<ORT:SSlJf DONATIONBHNCO~S'CH'fD? ; 26<; WA5COI';SENTGRAN1ED'
<br />Q YES 0 NO D PR0!36JllY "!:.'tm~NOWH J :lI YES _:-l NO i NOllppll"..bl. ~26~_I._._NO 0 VES~ _~_____
<br />'-~~~Ti - --~~D~~~~Ci~~iY~~,~c.o~R'S PKY$ii~NOR((' A1TOfiNEY1(fy,:e,~~~ ~ . ~-----;::~.; h;>--~-1-.a."'~12 2. ..
<br />.....,._ _.,..,._~,,~.~.i^...-.._{~1.f2L....,. ~~_.:z~",~...s:/Id___,~,_~_,_"~_,~J.._~.".~,, -"]
<br />
<br />2Sa fIE" SS~~ A "",_-"".u- I 28~ DATE F1LE(' BV RfG!STRAR l.lo Day, VI)
<br />
<br />~~~~~,_..____~,,__~_!.~~06_..__
<br />
<br />". '",t;.
<br />
<br />Th~~rtifi~hi~eU-~~llt to ~a true copy of an origin<JI record on filc with Vital Statistics, Douglas County
<br />HeaJJi! 'D.ept.,~maha, ~ras~~': Certified copies must h:>vc a raised seal in the area to the \eft. Reproductions
<br />of't~.r~.:: ce,{ijifate ~renotJtgal copies.
<br />..>y . . . ..'- '<;.,^
<br />Date It;;ue.dt; ~11.Wl. a .1~6
<br />, -<.,' 11M'~
<br />
<br />IMMffllA TE CAlJSE {F1....
<br />
<br />"Q, IF F(l/AlE.
<br />~N(" ","1"''1' will,in P": I'"
<br />~] P't':QMH'lt?1 tim@ of dE:alh
<br />o "101 pri?~r'<lnt, but pr{:T,~fil 'h'i:hir..2 .:ICly~ 0' df.&lh
<br />
<br />1a IIA~NER Of DEATH
<br />~:~1ura' :J I-kllll",--ide
<br />
<br />o AC{"lljenlC] Pefldio/Jlf'IVf ~ti~aHon
<br />
<br />Registrar:
<br />
<br />AcLC;::,~~~
<br />
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