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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~TRUE~COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEP~~~Tl~I:'~$ALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL ~'ITORt FCta/,
<br />VITAL RECORDS. . ~~I .... . ,,~..,
<br />
<br />2007000'71 ~/l~:,~
<br />
<br />STANLEY I~R?PPE~, IJ~RE..,~OR
<br />BUREAU OFA IV~~i:rTA~;~.ics
<br />
<br />'\. \. ,., \~'" ".,,'
<br />STATEOFNEBRASKA-DEPARTMENTOFHEALTH CJ2 10' 059.0
<br />BUREAU OF VITAL STATISTICS. ~,oJ-
<br />CERTIFICATE OF DEATH "
<br />
<br />DATE OF ISSUANCE
<br />
<br />DEe S (l) 1991
<br />LINCOLN, NEBRASKA
<br />
<br />1 DECEDENT, NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2 SEX
<br />
<br />;3 DATE Of: OEA fH (Month. Day. Year)
<br />
<br />ii St. Francis
<br />9.. RESIDENCE - STATE
<br />
<br />
<br />Richard
<br />
<br />Filbin Jr.
<br />'ii:l A~E - Las' eirthrlR~ f:.R~~
<br />IY"., 50. MOS DAYS
<br />58
<br />
<br />Male November 29 1991
<br />._,~D.E8.LQAL_ .,6 DATE" O~ BII=!TH (Mon"", Day Ys,at!
<br />5c. >10URS' MINS
<br />
<br />.",.., CITy Al-lG SrATe. .J:; S~~-r:-:
<br />
<br />(,If r!~! in !,.,',S,A, 'rC!~~ C';;":.1~'~l",1
<br />
<br />~eartwell. Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />November 6
<br />
<br />1933
<br />
<br />Ii 508 38-0968
<br />
<br />.llb FACILITY - Nam.
<br />
<br />HOSPITAL' Xi Inp."'''' 0 ER.Oulpa".nl 0 DOA
<br />
<br />OTHER 0 Nur$lng Hom8 0 Resujence 0 O*her fSfH'CifyJ
<br />8<;. CITY. TOWN OR LOCATION OF DEAT>1 8<1. INSIDE CITY LIMITS
<br />(Spoc<ly Y.. Of No/
<br />
<br />- 15. FATHER. NAME
<br />.
<br />
<br />MIDDLE
<br />
<br />
<br />Grand Island
<br />9<;. CITY, TOWN OR LOCATION
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />t 1. ANCESTRY te.g.Jlahan, M8lr:ican, German, etc.)
<br />(Spoclfy)
<br />
<br />White
<br />148, USUAL QC:.CUP,6,TION (G,v~ kincl Of work 110M during mO$I
<br />01 rKri,"O Ide. 8Vfffl if '.",1'1.1) ...., 3
<br />J Sales & Service ..d.
<br />
<br />L No
<br />
<br />COlleg. 11-4 0' 5-1
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />_ Richard R.
<br />
<br />- 1 B. i/AS DECEASED EVER IN U.S. ARMED FORCES?
<br />{Yes. no, or unk,l (If yes. give wat and dales or servlcesl
<br />
<br />
<br />20c
<br />
<br />21.
<br />
<br />Wood River Nebraska
<br />ISTREET OR RFD NO., CITY OR TOWN, STATE. ZIP I
<br />
<br />Apfel Funeral Home. Wood River. Nebraska 68883
<br />
<br />S:NTE;;;;~UC;;NL;R 181.101'21} ~ ~~ ~/~;:;~ ;;;;;;;;;;::....h
<br />
<br />InleNal between onset and death
<br />
<br />'J
<br />'I
<br />J
<br />
<br />=
<br />
<br />I!,> ~
<br />DUE TO, OR AS A CONSEQUENCE OF,
<br />
<br />l!"\t@I'\.a.! betw"n onSfji 20M deioih
<br />
<br />OT>1ER SIGNIFICANT CONDITIONS. Cond;lIOn' contrlbUllnQ to dO.'" OUl nol talate<l
<br />
<br />p~rT CO,p D
<br />
<br />
<br />PART III IF FEMALE, WAS THERE A 24. AUTOPSY
<br />PREGNANCY IN T>1E PAST 3 MONTHS? ISpeclfy Yo. 0' No)
<br />
<br />Y.. 0 No 0 No
<br />26d DESCRIBE >lOW INJURY OCCURRED
<br />
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />1~lfy Y.. Of No)
<br />
<br />26., ACCIDENT. SUICIDE, >lOMICIDE. UNDET., 2110. DATE OF INJURY (Mo..D'y, y,.)
<br />OR PENDING INVESTIGA nON ($pfJcdy)
<br />
<br />:!60. INJURY AT WORK
<br />(Spoclly Y.. Of No)
<br />
<br />STREET OR RF.D NO
<br />
<br />C;TY OR TOWN
<br />
<br />STATE
<br />
<br />27. DATE OF DEAT>1 (Mo.. DII(' Y<.)
<br />II - )..q - '" /
<br />
<br />- Ii ~ 27b;3E:0; ~ 7' Yf.)
<br />
<br />
<br />! f 274. To lho bN' of my kn0wte4g0.
<br />... causo(.) _.
<br />
<br />..n<lTIIte"
<br />
<br />29a. DID T08ACCO USE CONTRIBUTE TO T>1E DEATH?
<br />
<br />~ES 0 NO 0 UNKNOWN 0 YES ~ NO
<br />
<br />31, NAME AND ADDRESS OF CERTIFIER IPHYS'CAN. CORONER'S P>1YSICAN OR COUNTY ATTORNEYI (Typo Of Pf,ol/
<br />
<br />25.. DATE SIGNED (110.. Day. YO
<br />
<br />290. TIME OF DEA T>1
<br />
<br />32.. REGISTHAR
<br />
<br />
<br />&s~
<br />li~>-
<br />~u~
<br />
<br />288, On tne basis of .~.mtnattoo and10r investigation. in mV opinion deat,", oecurr~ at
<br />tI'IelirM. date and place and due to the cause/5) stated.
<br />
<br />28<;. PRONOUNCED DEAD lMo. (Jay. Yf.)
<br />
<br />28<1 PRONOUNCED DEAD lHau')
<br />
<br />300. WAS CONSENT GRANTED?
<br />
<br />eYES
<br />
<br />)(NO
<br />
<br />908 N. Howard Av. Box
<br />
<br />
<br />llOS
<br />
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