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The South Half (S1 /2) of Lot Thirteen (13), and all of Lot Twelve (12), Block Nine (9),
<br />Harrison's Subdivision to the City of Grand Island, Hall County, Nebraska.
<br />200704559 STATE OF ARIZONA
<br />ORIGINAL STATE OF ARIZONA
<br />STATE DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS DEATH NO.
<br />CONY CERTIFICATE OF DEATH
<br />D-102 2007 0 1 55PW�
<br />NAME OF A. FIRST B. MIDDLE C. LASE
<br />SEX
<br />DATE OF MONTH DAV YEAR
<br />DECEASED
<br />nn
<br />DEATH
<br />1. DONALD HARMON
<br />APRIL 29, 2007
<br />2MALE
<br />,.
<br />RACE (e.g., white, black, American Indian, (epeo6y lrlbe)etc.
<br />WAS DECEDENT OF HISPANIC ORIGIN:
<br />IF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN,
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />SPECIFY:
<br />(SPECIFY YES OR NO)
<br />CUBAN, ETC.
<br />(SPECIFY YES OR NO)
<br />4A. WHITE
<br />A A
<br />4C.
<br />C
<br />ICY
<br />CI►
<br />SC. HOSPITAL OR (IF RESIDENCE, GIVE STREET ADDRESS)
<br />(J
<br />INSTITUTION
<br />❑ DOA
<br />6. MARTCOPA
<br />Z
<br />KINDRED HOSPITAL
<br />_
<br />O
<br />] IN PATIENT
<br />DATE OF MONTH DAY YEAR
<br />AGE (YEARS
<br />IF UNDER 1 YEAR
<br />IF UNDER 1 DAY
<br />MARRIED, NEVER MARRIED,
<br />SURVIVING (IF WIFE, GIVE. MAIDEN NAME)
<br />BIRTH JUNE 8, 1931
<br />7.
<br />LAST�rJRTHDAY)
<br />MOS. DAYS
<br />HRS, MIN.
<br />WlDRAK§ r6CED (SPECIFY)
<br />IIL�I�A J, tt BUJ
<br />SPOIJ.jEN C{1NNOT
<br />�{��
<br />9A.
<br />B$.
<br />9C.
<br />Fr' _
<br />='
<br />STATE AND (11 not In USA, name country)
<br />cz�
<br />err
<br />t
<br />$ 7
<br />Q � �� `
<br />CA
<br />zoo U.S.A.
<br />1J 506 -34 -7573
<br />OF ROADS GOUT.
<br />14A. ROAD CONSTRUCTION
<br />148.
<br />USUAL 1SA, STATE
<br />RESIDENCE
<br />15B. COUNTY
<br />15C. TOWN OR CITY
<br />15D. ZIP CODE
<br />HOW LONG IN ARIZpNA7
<br />EDUCATION
<br />1,NEBRASKA
<br />�nrr
<br />GRAND ISLAND
<br />68801
<br />MONTHS
<br />HIGHEST GRADE COMPLETED
<br />156
<br />17
<br />STREET ADDRESS OF R.F D•
<br />1419 N. LAFAYETTE
<br />INSIDE CITY LIMITS? :
<br />(SPECIFY Yes or No)
<br />ON RESERVATIONS,
<br />(SPECIFY Yas or No)
<br />PREVIOUS STATE •;,
<br />OF RESIDENCE
<br />ELEMENTARY
<br />ELEMENTARY SECONDARY
<br />COLLEGE
<br />,SE.
<br />1$F YES
<br />15G NO
<br />16 NEBRASKA
<br />1aA 12
<br />ry -LLEGE
<br />188.
<br />FATHER'S A. FIRST B. MIDDLE C. LAST
<br />MOTHER'S MAIDEN A. FIRST B. MIDDLE C. LAST
<br />NAME
<br />19. MORRIS ". HARMON
<br />NAME
<br />20 MABEL JOHNSON
<br />INFO NAT
<br />RELATIONSHIP 70
<br />ADDRESS STREET NO. CITY AND STATE ZIP CODE
<br />DECEASED
<br />21.1 ANN HARMON
<br />22. WIFE
<br />Z31419 N. LAFAYETTE„ GRAND ISLAND, NEBRASKA 68BO1
<br />TT7
<br />DATE
<br />E L 'S SIGN TUBE .�
<br />Cn
<br />AA
<br />GRAND ISLAND, NEBRASKA
<br />8359
<br />25.05/02/07
<br />x-
<br />_x:
<br />Ul �wr�
<br />FUNERAL HOME NAME STREET ADDRESS CITY AND STATE,..,
<br />DIR or persona g �uuh (SIGNATU
<br />CERT, NO
<br />29 SONORAN SKIES MORTUARY 5650 E. MAIN STREET MESA, AZ. 85 05
<br />*CHRI8TINA DUWEL
<br />1211
<br />I i
<br />W
<br />TO THE BEST OF MY KNOWLEDGE, DLATH OCCURRED AT THE ME, DATE AND LACE AND
<br />ON'T HE S � E,'dAMINA710N ANWOR INVESTIGATION, IN MY OPINION DEATH OCCURRED
<br />J
<br />z O
<br />DUE. TOT HE CAUSE(S) STATEDD.
<br />30. SIGNATURE' 1 I
<br />AND TITLE N
<br />ATTHE IF DATE AND PLACE DUE TO THE CAUSE(S) AND MANNLH STATED.
<br />9q SIGNATURE
<br />z 0
<br />t
<br />}
<br />AND TITLE
<br />C5
<br />6
<br />DA'TL SIGNED (Mo., Day, Year)
<br />HOUR OF UEA7LI
<br />� �
<br />DATE SIGNED (Mc,!Day, Year) HOUR
<br />C.171
<br />Cf)
<br />Co
<br />32. 7:30 A.M.
<br />6
<br />35 36.
<br />NAME, OF ATTENDING PHYSICIAN OF OTHER THAN CLRTIFIER (Type nr pnrrg "'
<br />F- y
<br />P917NOUNCEO DEAD (Mo.. Day, Year) PRDNOUNCED
<br />DEAD (Hour)
<br />The South Half (S1 /2) of Lot Thirteen (13), and all of Lot Twelve (12), Block Nine (9),
<br />Harrison's Subdivision to the City of Grand Island, Hall County, Nebraska.
<br />200704559 STATE OF ARIZONA
<br />ORIGINAL STATE OF ARIZONA
<br />STATE DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS DEATH NO.
<br />CONY CERTIFICATE OF DEATH
<br />D-102 2007 0 1 55PW�
<br />NAME OF A. FIRST B. MIDDLE C. LASE
<br />SEX
<br />DATE OF MONTH DAV YEAR
<br />DECEASED
<br />DEATH
<br />1. DONALD HARMON
<br />APRIL 29, 2007
<br />2MALE
<br />,.
<br />RACE (e.g., white, black, American Indian, (epeo6y lrlbe)etc.
<br />WAS DECEDENT OF HISPANIC ORIGIN:
<br />IF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN,
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />SPECIFY:
<br />(SPECIFY YES OR NO)
<br />CUBAN, ETC.
<br />(SPECIFY YES OR NO)
<br />4A. WHITE
<br />4B. NO
<br />4C.
<br />5. YES
<br />PLACE OF 6A. COUNTY
<br />68. TOWN OR CITY
<br />SC. HOSPITAL OR (IF RESIDENCE, GIVE STREET ADDRESS)
<br />DEATH
<br />INSTITUTION
<br />❑ DOA
<br />6. MARTCOPA
<br />SCOTTSDALE
<br />KINDRED HOSPITAL
<br />OF EMER.
<br />] IN PATIENT
<br />DATE OF MONTH DAY YEAR
<br />AGE (YEARS
<br />IF UNDER 1 YEAR
<br />IF UNDER 1 DAY
<br />MARRIED, NEVER MARRIED,
<br />SURVIVING (IF WIFE, GIVE. MAIDEN NAME)
<br />BIRTH JUNE 8, 1931
<br />7.
<br />LAST�rJRTHDAY)
<br />MOS. DAYS
<br />HRS, MIN.
<br />WlDRAK§ r6CED (SPECIFY)
<br />IIL�I�A J, tt BUJ
<br />SPOIJ.jEN C{1NNOT
<br />�{��
<br />9A.
<br />B$.
<br />9C.
<br />9. 10.
<br />STATE AND (11 not In USA, name country)
<br />CITIZEN OF WHAT SPECIFY
<br />SOCIAL SECURITY N0.
<br />U N Qive kind of work
<br />d��gl�e,avanK mirad)
<br />$ 7
<br />Q � �� `
<br />,�L�FCMLUFF, NEBRASKA
<br />zoo U.S.A.
<br />1J 506 -34 -7573
<br />OF ROADS GOUT.
<br />14A. ROAD CONSTRUCTION
<br />148.
<br />USUAL 1SA, STATE
<br />RESIDENCE
<br />15B. COUNTY
<br />15C. TOWN OR CITY
<br />15D. ZIP CODE
<br />HOW LONG IN ARIZpNA7
<br />EDUCATION
<br />1,NEBRASKA
<br />HALL
<br />GRAND ISLAND
<br />68801
<br />MONTHS
<br />HIGHEST GRADE COMPLETED
<br />156
<br />17
<br />STREET ADDRESS OF R.F D•
<br />1419 N. LAFAYETTE
<br />INSIDE CITY LIMITS? :
<br />(SPECIFY Yes or No)
<br />ON RESERVATIONS,
<br />(SPECIFY Yas or No)
<br />PREVIOUS STATE •;,
<br />OF RESIDENCE
<br />ELEMENTARY
<br />ELEMENTARY SECONDARY
<br />COLLEGE
<br />,SE.
<br />1$F YES
<br />15G NO
<br />16 NEBRASKA
<br />1aA 12
<br />ry -LLEGE
<br />188.
<br />FATHER'S A. FIRST B. MIDDLE C. LAST
<br />MOTHER'S MAIDEN A. FIRST B. MIDDLE C. LAST
<br />NAME
<br />19. MORRIS ". HARMON
<br />NAME
<br />20 MABEL JOHNSON
<br />INFO NAT
<br />RELATIONSHIP 70
<br />ADDRESS STREET NO. CITY AND STATE ZIP CODE
<br />DECEASED
<br />21.1 ANN HARMON
<br />22. WIFE
<br />Z31419 N. LAFAYETTE„ GRAND ISLAND, NEBRASKA 68BO1
<br />BURIAL, CREMATION,
<br />REMOVAL, OTHER (Specify)
<br />DATE
<br />CEM�TR�VyLA A ft
<br />Wk 5 I LHIIJIU I *ItIrI��MI(r} CEMETERY ERY
<br />E L 'S SIGN TUBE .�
<br />CERT. NO.
<br />REM /BURIAL
<br />GRAND ISLAND, NEBRASKA
<br />8359
<br />25.05/02/07
<br />2s.
<br />27di:1►GHRI:STINA DOWEL
<br />FUNERAL HOME NAME STREET ADDRESS CITY AND STATE,..,
<br />DIR or persona g �uuh (SIGNATU
<br />CERT, NO
<br />29 SONORAN SKIES MORTUARY 5650 E. MAIN STREET MESA, AZ. 85 05
<br />*CHRI8TINA DUWEL
<br />1211
<br />29A
<br />TO THE BEST OF MY KNOWLEDGE, DLATH OCCURRED AT THE ME, DATE AND LACE AND
<br />ON'T HE S � E,'dAMINA710N ANWOR INVESTIGATION, IN MY OPINION DEATH OCCURRED
<br />J
<br />z O
<br />DUE. TOT HE CAUSE(S) STATEDD.
<br />30. SIGNATURE' 1 I
<br />AND TITLE N
<br />ATTHE IF DATE AND PLACE DUE TO THE CAUSE(S) AND MANNLH STATED.
<br />9q SIGNATURE
<br />z 0
<br />t
<br />}
<br />AND TITLE
<br />C5
<br />6
<br />DA'TL SIGNED (Mo., Day, Year)
<br />HOUR OF UEA7LI
<br />� �
<br />DATE SIGNED (Mc,!Day, Year) HOUR
<br />OF DEATH
<br />s
<br />s,. 04/30/07 _ _
<br />32. 7:30 A.M.
<br />6
<br />35 36.
<br />NAME, OF ATTENDING PHYSICIAN OF OTHER THAN CLRTIFIER (Type nr pnrrg "'
<br />F- y
<br />P917NOUNCEO DEAD (Mo.. Day, Year) PRDNOUNCED
<br />DEAD (Hour)
<br />33.
<br />37. ON 36.
<br />AT
<br />NAME AND ADDRESS OF CERTIFIER, PHYSICIAN, MEDICAL E XAMINER OR TRIBAL LAW ENFURC LY�
<br />TEHCO D;FCiR•pREMATION
<br />MEDICAL EXAMINER'S SIGNATURE
<br />,�,"TR UNDER K. SONI M.D. 1402 N. MILLER RD. #C3 52 7
<br />JYda KNo
<br />141.
<br />DATE RE(,
<br />FILL NU.
<br />REGISTRAR' SIQN4T RE � '" ''
<br />REG. 136 CT
<br />DATE REC'O IN STATE OFFICE
<br />yREGISTERED
<br />477At Q $ 2W q9
<br />940B
<br />\'*�
<br />JON
<br />aa., - . F�
<br />ON
<br />45.
<br />4G.
<br />•
<br />47A IMMEDIATE CAUSE (FINAL DISEASE OR CONDI RESULTING IN ATH) (ENTF. LV U CAUSE EACH LINE)
<br />FUL MOIJOP-1 4*XrLST , P' isPIRlkT.2r FAILURE.
<br />Y u' ®Z
<br />i 5
<br /><
<br />478. DUE TO OR AS A CONSEQUENCE OF
<br />VAL
<br />EN
<br />2
<br />F.
<br />G a P �
<br />4A-PPROXIMATE
<br />T
<br />47C. DUE T O OR AS A CONSEQUENCE OF:
<br />H
<br />PART 11. Other aignlflcant copQ61pd5 contributing to death but not resulting in the underlying cause given in Part I
<br />AUTOPSY
<br />WAS CASE REFERRED TO MEDICAL EXAMINER
<br />'
<br />(Specify Ya5 or No)
<br />(Specify Yee or Nn)
<br />49, NO
<br />50 ND
<br />MANNER OF UEATH
<br />f
<br />NSiIFEAE
<br />❑
<br />DATE OF MO DAY YR
<br />INJURY
<br />HOUR
<br />INJURY AT WORK?
<br />IS city Yes or Na)
<br />DESCRIBE HOW INJURY OCCURRED
<br />coiE� L J �pc�
<br />PENDING
<br />52.
<br />53. M
<br />54.
<br />55.
<br />ACCIDENT 11`A'fiSRGSMN
<br />PLACE OF INJURY (At hnme. farm, street, lactory, office building, etc.)
<br />SPECIFY
<br />WHERE LOCATED? STREET ADDRESS CITY OR TOWN STATE
<br />9.AOCE' LhDEfBTv1N�
<br />I
<br />51.
<br />56.
<br />57.
<br />6.00 1
<br />
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