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<br />'lease record the death certificate against the following described legal description:
<br />
<br />Lot Seven (7), in Block Fourteen (14), in H.G. Clark's Addition to the City of Grand Island,
<br />Hall County, Nebraska.
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ~ltQrN ~s "l'
<br />SYSTEI'd, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO, I;JJi FILE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TIST/gSt;{:JJ:!I/t/liJ;!JE,H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. 4m<;=-~:~~~:-~"i'
<br />
<br />DA TE OF ISSUANCE . 4fJ.' '- - c~
<br />11/21/2003 20060612 4 I.~,.- if _'A~~_s.~c~~
<br />AS~TAHTM~~R:
<br />LINCOLN, NEBRASKA _ HEALTH ANQ.'1!,~.f.l-I6~~$~1Ij
<br />-~'=-l-. '" - ~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTII AND HUMAN sml'~~AND ~i-
<br />VITALST;.TISTICS 'C\ "'~. .,:,,~ --,-..-~_.
<br />CERTIFICATE OF DEATH "L:~~~2':#'i'"",-~~== .-D 3 13006
<br />,. OECEOENT - NAME FIRST MIOOlE lAST t SEX
<br />
<br />Byron
<br />4, CITY ANO STATE OF BIRTH lllnotin U,S,A" nama country)
<br />
<br />Wayne
<br />
<br />Skeen
<br />
<br />
<br />Male
<br />
<br />14. 2003
<br />
<br />58. AGE - last Blrtllday
<br />IY".I 63
<br />
<br />UNOER , YEAR
<br />5b. MOS, DAYS
<br />
<br />6. OATE OF SIRTH (Month. Day, Year!
<br />
<br />October 20. 1940
<br />
<br />Shelton. Nebraska
<br />7. SOCIAl SE;CURTIY NUMaE;R
<br />
<br />88. PlACE OF DEATH
<br />HOSPITAl: [Xl Inpaliant
<br />D E;R OUlp.tlolll
<br />o OOA
<br />
<br />OTHe~: D Nursing Home
<br />D Residence
<br />
<br />D Other (SpeclfYI
<br />
<br />506-50-9800
<br />
<br />8b. FACIUTY" Name
<br />
<br />(U flot institution, give street afJd numbBr)
<br />
<br />St. Francis Medical Center
<br />
<br />8e. CITY, TOWN OR lOCATION OF OEATH
<br />
<br />8d. INSIDE CITY liMITS 8e, COUNTY OF DEATH
<br />
<br />Grand Island
<br />
<br />8.. HcSIDENCE - STATE 'ilii'COUNTY--'~-'"
<br />
<br />Yes [!] No D Hall
<br />"90, CITY.TOWN OR lOcATlON~-'- 9d, ~SiREET AND NUMBER (tnt:/uding Zip Code)
<br />
<br />9.. INSIOE CITY LIMITS
<br />
<br />Nebraska
<br />
<br />
<br />15. EDUCATION (SpOClly only nighest grade completed)
<br />Elememar'Yf''6,eeonClaI'Y /0-12) College 11-4 Or 5.J..1
<br />
<br />Grand
<br />
<br />68801 Ye. [] No D
<br />13, NAME OF SPOUSE (If wile. give maidennamB)
<br />
<br />
<br />10. RACE:. (e.g., White, Black. American kldlan.
<br />elc.IISpecify! Wh it e
<br />
<br />11, ANCESTRY 'e.g" ""Iian. Me.,c.n. German, .lel
<br />ISpoCllyj
<br />
<br />Ruth Martin
<br />
<br />American
<br />
<br />140, USUAl OCCUPATION IGlVe kind 01 work done dllring most
<br />01 wNkmg 1l1e, even if fefirliftrlj
<br />Journeyman Gasman
<br />
<br />16. FATHER - NAME FIRST
<br />Louis
<br />
<br />Northwestern Energy
<br />lAST 17. MOTHER
<br />Skeen
<br />
<br />MIDDlE
<br />
<br />MAIDEN SURNAME
<br />Stairs
<br />
<br />
<br />FIRST
<br />Evelyn
<br />
<br />MIDDlE
<br />Wendell
<br />
<br />16, WAS DECEASEO EVER IN U,S, ARMEO FORCES?
<br />(Yes. no. or ullk;,) (If yes. give war and dates of services'
<br />No Ruth Skeen
<br />
<br />lab. INFORMANT MAiliNG ADORESS ISTREET OR R.F-O. NO.. CITY OR TOWN, STATE. ZIPI
<br />
<br />Grand Island. Nebraska
<br />21 a. METHOD DF DISPOSITION 21 b. OA TE
<br />
<br />68801
<br />
<br />
<br />21 c, CEMETERY OR CREMATORY NAME
<br />
<br />[!I Surial D Remov.1 Noveriler 17 2003
<br />210. CEMETERY OR CREMATORY lOCATION
<br />
<br />#1071
<br />
<br />MEmJrial Park Caret
<br />CITY OR TOWN STATE
<br />
<br />All Faiths
<br />.2b. FUNERAl HOME ADDRESS
<br />
<br />D Cremation D Dooallon
<br />
<br />Grand Island.
<br />
<br />Nebraska
<br />
<br />Funeral Home
<br />(STREET OR R.F.O. NO.. CITY OR TOWN, STATE. ZIP)
<br />
<br />2929 S. Locust St..
<br />23. IMMgOIATE CAUSE
<br />PART
<br />I
<br />
<br />Grand Island. Nebraska
<br />(ENTER ONlY ONE CAUSE PER liNE FOR ISI.lbl. ANO 1011
<br />
<br />68801
<br />
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<br />25. WAS CASE REFERRED TO MEDICAl
<br />EXAMINER OR CORONER?
<br />No X
<br />
<br />h
<br />
<br />101
<br />PART OTHER SIGNIFICANT CONDITIONS - Condition. contributing to tIla d.ath but nat ralstod
<br />
<br />"
<br />
<br />26..
<br />
<br />
<br />26b, OATE OF INJURY (Mo" Day. Yr.! 26c, HOUR OF INJURY
<br />
<br />o Accident D Undetermined
<br />D $l,llcide D P~nding
<br />o Hornicige InvestIgation
<br />
<br />26.. INJURY AT WORK
<br />YesD NoD
<br />
<br />269, lOCATION
<br />
<br />STREET OR R.F.O. NO.
<br />
<br />CITV OR TOWN
<br />
<br />STATE
<br />
<br />27.. OA TE OF OEA TH (Mo" DRy, Yr.!
<br />
<br />288. DATE SIGNED (Me.. Day. Yrj
<br />
<br />28b. TIME OF DEATH
<br />
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<br />
<br />28c. PRONOUNCED DEAO (Mo.. Day., Yr,)
<br />
<br />28<1. PRONOUNCED DEAO (Houfl
<br />
<br />
<br />A. M
<br />
<br />~ NO
<br />
<br />31,
<br />
<br />Thomas F.
<br />32.. REGISTRAR
<br />
<br />
<br />Faidle
<br />
<br />Grand Island NE
<br />32b, OATE FllEO BY REGISTRAR IMo.. Day. Yr)
<br />
<br />NOV 2 0 2003
<br />
<br />68803
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