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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE_,
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRt� 0QPYj;','t
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT '(Oiin,&I ;,
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITQRY,:FOR 'a ✓,,f;
<br />VITAL RECORDS.
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<br />DATE OF ISSUANCE 2 0 0 6 0 9 8 9 1 .: r-
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<br />MAR 1992 STANLEY S. COOFaE i.� •,��'�
<br />LINCOLN, NEBRASKA BUREAU OF VITAL �%TA I� aIGS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />1. DECEDENT - NAME FIRST MIDDLE LAST 2
<br />2. SEX 3
<br />3. DATE OF DEATH (Month. Day. Year1
<br />4. CITY AND STATE OF BIRTH (It norm U.S.A., name Country) 5
<br />5a AGE - Last B,nhday 6
<br />_Cld 1
<br />5b. MOS. DAYS 5
<br />5c. HOURS, MINS
<br />(Yrs. 5
<br />7. SOCIAL SECURITY M ggR Sa. PLACE OF DEATH
<br />HOSPITAL. ❑ Inpatient E ER Outpatient L DOA
<br />--
<br />Ob FACILITY • Name`"- /If not rnst/lutbn, give sheet acrd number) St. CI WN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />( Specfy Yes or No.1
<br />St Francis Memorial Health C r Grand Island Yes I Hall
<br />g0. RESIDENCE • STATE 9
<br />9b. COUNTY 9
<br />9c. CITY, TOWN OR LOCATION 9
<br />9d STREET AND NUMBER (Including Zrp Codel 9
<br />9e. INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />Nebraska H
<br />Hall G
<br />Grand Island V
<br />Via TriyQli Y
<br />Yes
<br />10. RACE - (e.g., White. Slack, Amencan Inman, 1
<br />11. ANCESTRY le.g.,ltahan, Mexican, German. etc.) 1
<br />12 MARRIED.NEVER MARRIED, t
<br />t 3. NAME OF SPOUSE (if -to. give matden name)
<br />ett.I fspecrfy) /
<br />/Specify) W
<br />WIDOWED, DIVORCED (Spectyl
<br />White I
<br />Irish - %r� M
<br />Married J
<br />Janice Mensen
<br />14a. USUAL OCCUPATION (give kind of work done during mast 1
<br />14b. KIND OF BUSINESS INDUSTRY n
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<br />Elementary or Secondary 10 -121 College 0 -4 or 5� I
<br />of working Life, even it retired) E
<br />6rner1cerator E
<br />E Motor Repur 1
<br />1,
<br />16. FATHER -NAME FIRST MIDDLE LAST t
<br />t 7 MOTHER -MAIDEN NAME �...f FIRST _.,.. MIDDLE LAST �^
<br />James McNanna
<br />16. WAS DECEASED E
<br />EVER IN U.S. ARMED FORCES' 1
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />(Yea, no, or unk.) (
<br />(It yea, grye at and dates df 60rwc051 OA /i7 /4r1 J
<br />Janice McNannay -Wife
<br />11,0 114 Tri-Ali r- 2
<br />208 BU I remation,Remdva, b
<br />b. DATE •
<br />Y MA R - �
<br />�I TOWN STATE
<br />Donation
<br />urial �
<br />�,tjnqs NP
<br />E MER - SIGNATURE d LI NSE 0 y 2
<br />22. FUNERAL HOME - NAME AND ADDRESS" (STREET OR H.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />7� "1 UP iliol
<br />IMMEQIA CAUSE R 0 L O E CAUSE PER LI FOR )al. Ib), AND (c)1 'Interval between onset and death
<br />PART
<br />lei
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />Let _
<br />_..._.. -._..
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - C ndltlo ;--.° L'eu!_nfyt death bu: '.UI 'elated °
<br />°ART I()JFFE.&61, WAS,it16RE A:,.- ... -,� oivi. 0
<br />00'�fyy;.
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<br />LFrAL DESCRIPTTONt Lot Twenty Fight (28)
<br />an Addition to the city of Grand Island,
<br />Plock One (1) Continental. Gardens
<br />Hall County, Nebraska
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