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<br />bOOK 1082
<br />
<br />PAGE 639
<br />
<br />.'
<br />
<br />DOUQLAS COUNTY HEALTH DEPARTMENT
<br />VITAL STATISTICS SECTION - OMAHA. NEBRASKA
<br />CERTIFICATE OF DEATH
<br />
<br />259300
<br />
<br />
<br />1 DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH (Month, Dsy, Y.")
<br />
<br />Gerald
<br />
<br />D.
<br />
<br />.. CITY AND STATE OF BIRTH (If not on VS.A., nSm, COuntry)
<br />
<br />
<br />Lichty
<br />
<br />5a. AGE. LAst Birthday
<br />IY"60
<br />
<br />Male
<br />
<br />Brunswick, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-34-8611
<br />
<br />Sb MOS
<br />
<br />DAYS
<br />
<br />5e, HOURS'
<br />I
<br />
<br />MINS
<br />
<br />
<br />August 9, 1992
<br />8, DATE OF BIRTH (Month. Doy, Y..,)
<br />September 18, 1931
<br />
<br />1 B. FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />
<br />HOSP!L~ 0 In~n' 0 EROu'pa".n, 0 DOA
<br />OTHE~_: 0 NurSing Home ReSidence 0 Other {Speedy)
<br />8e. CITY, TOWN OR LOCATION OF DEATH ed. INSIDE CITY LIMITS
<br />Omaha (f;~Yesa"'IO!
<br />
<br />. 8b. FACILITY - Name
<br />
<br />(If not instItution, gIve strut ana number}
<br />
<br />7704 Wirt
<br />
<br />
<br />Nebraska
<br />
<br />
<br />ge. CITY, TOWN OR LOCATION
<br />
<br />10. RACE - (e,g., Wnite, BlaCk. Amenc:an Indian,
<br />
<br />1,.%rt'~
<br />
<br />1 J. NAME OF SPOUSE (If wife, gIV8 maiden flam,)
<br />
<br />11, ANCESTRY le.g.,ltallan. MeXican. German, etc,)
<br />(Sp8I':/kij _
<br />
<br />_~er~_can
<br />148, USUAL OCCUPATION 10'.,. kind 01_ tf<m.-trlifl
<br />
<br />~r;~t"r ra~"If''''1
<br />
<br />LAST
<br />
<br />Cec 11
<br />
<br />R.
<br />
<br />M. Charf.
<br />ISTREET OR R,F.D. NO" CITY OR TOWN, STATE,llPI
<br />
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />l''fR"M. I)' !,Ink.j (II :res, gIVe war and d!ll~s Of services)
<br />
<br />Shirley Lichty wife 7704 Wirt Omaha, Nebr. 68134
<br />2Oc. CEMETERY OR CREMATORY. NAME 20d. LOCATION CITY OR TOWN ST A Ti'
<br />
<br />
<br />12, 1992
<br />
<br />Ewing Cemetery
<br />n. FUNERAL HOME. NAME AND ADDRESS
<br />
<br />Ewing, Nebraska
<br />ISTREET OR R.FD. NO, CITY OR TOWN, STATE. ZIP)
<br />
<br />21 EM ER . SIGNATURE & L1Cl5E NO
<br />
<br />\'cio,,' ~ ~A-6..
<br />
<br />23. IMMEDIA CAUSE
<br />PART
<br />I
<br />
<br />"'l..L.f Boyd E. Braman Mortuary Omaha, Nebraska 68114
<br />
<br />IENTER ONLY ONE CAUSE PER LINE FOR lal,lbl, AND lell
<br />
<br />Interval between onset and a.am
<br />
<br />Hemorrha e
<br />
<br />Ininediate
<br />Interval between onset al"ld death'
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF,
<br />
<br />Carotid Ar
<br />DUE TO, OR AS A CONSEQUENCE OF,
<br />
<br />Invasion b 'I'u:rror
<br />
<br />Inmediate
<br />Interval between onsel and dealt:'
<br />
<br />Cancer of the
<br />
<br />_~"",'_'---r
<br />
<br />~.7.. DATE OF DEATH
<br />
<br />
<br />Recurrent
<br />
<br />PART OTHER SIGNIFICANT CONDITIONS. Conditions contributing to death but not related
<br />"
<br />
<br />24. AUTOPSY
<br />(Spscify Y6s or No)
<br />
<br />Yeo 0 NO 0 No
<br />2fid. DESCRIBE HOW INJURY OCCURRED
<br />
<br />: 5 Years
<br />25. WAS CASE REFERRED TO MEt,
<br />EXAMINER OR CORONER?
<br />(Speelly Y"'ie~)
<br />
<br />2Ba. ACCIDENT, SUICIDE, HOMICIDE, UNDET, 28b. DATE OF INJURY (Mo"Osy, Y'.J
<br />OR PENDING INVESTIGATION (SpiCily)
<br />
<br />280. INJURY AT WORK
<br />(Specify Yss Of No}
<br />
<br />STREET OR RFD. NO
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />.28. DATE SIGNED IMo Day, Y'.J
<br />
<br />28b TIME OF DEATH
<br />
<br />8-9-92
<br />
<br />,--~.~_..
<br />
<br />~_...--
<br />
<br />"~
<br />It~
<br />
<br />8-14-92
<br />
<br />10:15 A.M.
<br />
<br />Is ~ ! 28e. PRONOUNCED DEAD (MO" Ooy, VI.J
<br />[t= _
<br />:;-2g
<br />
<br />~ ~ ~ 2Se, an the biil$l$ 01 examlriiUIOn and Of' Irive51lgatlon. In my opinion death occurred 111
<br />~ ,lhe time. dale and place and due 10 the causelsj stated
<br />
<br />ren M.D. (51 nature and Title)'"
<br />3Oa. HAS ORGAN O~ TiSSuE DONA"fION 8E:E.N ~O~$IDERI::.07 30b, WAS CONSENT ORANTEl;)?
<br />
<br />28d PRONOUNCED DEAD (Hou,!
<br />
<br />27~. DATE SIGNED (Mo., Osy, Y',I
<br />
<br />27e. TIME OF DEATH
<br />
<br />M
<br />
<br />270. To the be$t 0' my knowledge, death occurred al1ne time. date an(l Place and due to tne
<br />cause!s) stated
<br />
<br />IS, naMO .nd Hlel ~/ s/Frederic P.
<br />29a. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />10.
<br />
<br />~ YES 0 NO 0 UNKNOWN 0 YES ){i NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEYI (Type or Prmtl
<br />
<br />c: YES
<br />
<br />o NO
<br />
<br />Frederic
<br />32a. REGISTRAR
<br />
<br />
<br />, N. p. H.
<br />
<br />
<br />AUS
<br />
<br />IMPRINTED SEAL
<br />REGISTER OF DEEDS
<br />
<br />200700938
<br />
<br />This certifies this document to be a true copy of an original record on file
<br />with the Vital Statistics Section of the Douglas County Health Department,
<br />Omaha, Nebraska. Certified copies must have a raised seal in the area to the
<br />left. Reproductions of this green certificate are not legal copies.
<br />
<br />AUG li1992~_
<br />
<br />f)...;.p ') · ~~ IU. H.
<br />
<br />-_.n__-~---rReg1.S rar --
<br />
<br />Date issued:
<br />
<br />Lot II -e;cf- \ / Petei'>~V\S Pr<JSf,c-t J.{.JI
<br />c~:=J]};_~Bi{_fD'a.R I'-IA-SIu'i-B 5'3 ~ 3030b
<br />T:;.~.!, 't:."D PG G~l C/O_ COMP .JrESCAN.#t.-
<br />FEtE 5 ~. OF W-S--:-UGL DG dJ'. . +
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<br />JUL I
<br />
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<br />
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<br />
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<br />
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