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<br />WHEN 711IS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND Ij~ .~~EY1CES
<br />,SYSTEM, fT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R~gtWtT;Hl!l'lf1J;i$W!IH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA T1ST:1(ltf ~1"llH:I;Wffl!;H!$
<br />
<br />:::;::~::::::TORY FOR VITAL RECORDS. ~.t/%C~~?"1f ~ ~i&'-~t~
<br />.JUtl12002 200705342 ::;~~::f:It::r~.~
<br />
<br />LINCOLN, NEBRASKA HEAL TH AND Hli!jAN-~E'!.r1~~~JME~
<br />
<br />STATE OF NEBRASKA- DEPARTMENT Of HEALTH AND HUMAN SER VlcES;1:(Ni\NcE-~'-s~RT
<br />VITAL STATISTICS ' :~, -,- =--0 " ---'---.:: c -0 2
<br />CERTIFICA TE OF DEA TH c~c:c.",-~~;.=-
<br />
<br />07829
<br />
<br />2 SEX
<br />
<br />
<br />June 29, 2002
<br />6. DATE OF SIA1H (Month D~)y ~.;~~;)-,....,,~
<br />
<br />j- "i"" DCU:LH::NT - NAMf
<br />
<br />FIRS"T---
<br />
<br />'~,iC.)()l.-c'
<br />
<br />LAS 1
<br />
<br />~l.i'AIE OF DEATH (MontlJ D<l~' '(2dr,'
<br />
<br />I James
<br />~y' A.ND STATE OF OIRTt-l fit not If) U S,A.. name c()unlryl
<br />
<br />Earl
<br />
<br />Keeshan Sr.
<br />
<br />Male
<br />UNDER 1 DAY
<br />5c. HOURS M1NS
<br />
<br />February 28, 1935
<br />
<br />Omaha, Nebraska
<br />
<br />~ 7 SOCIAL SECURTlY NUM8FR
<br />
<br />Sa AGt:: - Lasl l3irtMay uNDER 1 YEAR
<br />(Yr!i I Sb MOS DAyS
<br />67
<br />
<br />St. Francis Medical Center
<br />
<br />8, PLACE OF DEA TH
<br />HOSPITAL [] Inpatient
<br />o ER Ql)tPahent
<br />o DOA
<br />
<br />OTHt:R 0 NurSing HomL'
<br />
<br />o Residence
<br />
<br />o Other /SoeClfvI_
<br />
<br />508-36-3854
<br />
<br />.8b FACIliTY - Name {ffnatlnstitulion,givestreetilIlGmlmrer}
<br />
<br />10 HACE - (e,g., While, Black.. Ar'\')e~ican Indian
<br />e".IISoe~ i t e
<br />
<br />11. ANCESTAy'iog
<br />(Socclfyl
<br />
<br />
<br />8d INSIDE CITY liMn s 1812 COuNlv OF- DEATH
<br />
<br />Ye, [!J No 0 L Hall
<br />
<br />Cnv. TOWN OR LQCA1ION STRt:::Ef AND NUMBER (Inc:luding Zip (;odel
<br />
<br />ge INSIOF CITY LIMITS
<br />
<br />" Be CITY, TQWN OR LOCATION OF DEATH
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />
<br />Grand Island
<br />
<br />
<br />68801
<br />
<br />Ye, [] No 0
<br />
<br />9a. RI::SllJE:NCE - STATI:: COUN"fY
<br />
<br />American
<br />
<br />12. [Xl'MARRIED
<br />
<br />o Nt:.VER
<br />MARRIED
<br />141:) KIND OF BuSINESS INDuS TRY
<br />
<br />13 NAME OF SPOUSE {If wife f)/ve mil/den n,'1meJ
<br />Mary Ann Vetick
<br />
<br />; 14a USUAL. OCCUPATION (Give kind of !Wi''/': dono during mosl
<br />Of,..JVOfJu""-' Id~, ,8.1((;'" if fetired!
<br />. Owner/Operator
<br />
<br />,""16:'FA1HER:N'iiM~-- , FIRST MIDDLE
<br />
<br />Keeshan Trucking
<br />LAST I 7 MOTHER
<br />
<br />1 t). EDuCA liON (SpeClly only 1'lIgheSI grade LOI~lpletedl
<br />Elementarytteconclary 10.12) College II 4 Or :->"1
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Alfred
<br />
<br />
<br />Florence
<br />
<br />Kelly
<br />
<br />";aWAS-OECEASED EVER IN US ARMFD FORCeS'
<br />(Yes. 1"\0. or ullk.1 III yes.: Qlve war and dates of services.)
<br />No
<br />
<br />,NAME
<br />
<br />Mary Keeshan
<br />
<br />19b INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />ISTReoT OR RF 0 NO
<br />
<br />2208 Cottonwood
<br />
<br />NE.
<br />
<br />68801
<br />
<br />
<br />EMB MER - SIGNA 1 UHt:. .& LICENSE NO
<br />
<br />r"i/2 f!?,
<br />
<br />21 a METHOD OF DISPOSITION
<br />
<br />21b. DATE
<br />
<br />21c, CEMETERY.O'R-CRFMATORY NAME.
<br />
<br />o Burial
<br />
<br />o Removal
<br />
<br />July 2, 2002 Grand Island C~E1_etery___
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE=
<br />
<br />Apfel-Butler-Geddes
<br />
<br />o Cremation 0 Donation
<br />
<br />Grand Island!- NE
<br />
<br />. 22b FuNERAL HOME ADDRESS
<br />
<br />ISTREET OR RFD. NO.. CIIY OH lOWN. STATE. ZIPI
<br />
<br />1123 West Second.
<br />
<br />Grand Island,
<br />
<br />NE
<br />
<br />68801
<br />
<br />~~:~6;~o hU !nv~"rY
<br />
<br />DUETO. OR AS A CONS~E-NtE OF /
<br />
<br />101
<br />DUE TO. OR AS A CONSFOUFNCF OF
<br />
<br />26b DA TE OF INJURY (MfJ DnV, Yr.j
<br />
<br />?6c HOUR OF INJURY
<br />
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />----T'
<br />I
<br />I
<br />I
<br />
<br />IYr ih U 1/..5
<br />Interval between onset ana Cle(lth
<br />
<br />IENTER ONLY ONE CAuSE PER LINE FOR '"1. Ibl AND 1<11
<br />
<br />Interval between Onset JM ,1C;lUl
<br />
<br />4Yrt'sf:
<br />
<br />Inlerviil hf!lween onsel ,~rl(1 r,lf!:-!H'
<br />
<br />lei
<br />OTHFR SIGNIFICANt CONDITIONS
<br />
<br />,_~~~_lv
<br />2Sa II
<br />C.] Acclder)( LJ Urldetermlnec!
<br />[] SUIcide r'-l PeM,"~
<br />o Homicide
<br />
<br />- Conditions contributing to tne death but not related
<br />
<br />~6e INJURY A. T WORK
<br />
<br />Invp.stlqallor\
<br />
<br />Yes D No 0
<br />
<br />26f, PLACE QF IN.JURY - Al home, fil.rm !itft-!et. lac:tory
<br />offIce bUilding. elc (Soecify)
<br />
<br />2Gq, LOCATION
<br />
<br />STREET OR A.r.D, NO
<br />
<br />CI r y OR TOWN S 1 A 'l
<br />
<br />2701 DA T!: OFDEAl1T(MO "'6~y:.yt.i-~_.-~,~"
<br />
<br />2ij" OATF SIGNED (Ma, DnY. Yr,1
<br />
<br />j2B';
<br />
<br />TIME OF DEATH
<br />
<br />6-29-02
<br />
<br />27b OA 1 [SIGNED (Mo,. Day. Yr)
<br />
<br />liME OF DEATH
<br />
<br />~ ;~
<br />.. ~[ 'II
<br />i~g>-
<br />0. a... ~' ...J
<br />(~~ ~ l
<br />.8~~
<br />~Z~
<br />C) ,-,
<br />
<br />M
<br />
<br />~;' ~,
<br />M~
<br />.!l';>- :-"
<br />~,t '"
<br />(:S ~n
<br />!: ,:5"
<br />cd
<br />
<br />
<br />28c, PRONQUNCED DEAlJ IMo. Day, Yr.l
<br />
<br />28d. PRONOUNCED lJEAO (Houri
<br />
<br />7-02-02
<br />
<br />M
<br />
<br />M
<br />
<br />2Se On 1M oasis of examlnatron aM 'or investigation, In my Opinion death OCCu(f'ed at
<br />the time. date and place and due to the cause{s) stated
<br />
<br />29
<br />
<br />3O.b WAS CONSENT GRANTED'
<br />DYES
<br />
<br />[kI. NO
<br />
<br />DYES
<br />'31 NA-MEAND ADDHESS or CERTIFIER IPHYSICIAN. CORONeHS PHYSICIAN OR COUNTY ATTORNEY I tTyoe (Y p,inl!
<br />
<br />Thomas
<br />
<br />we~'D', 2444 w.
<br />
<br />d~tu
<br />
<br />Faidley Ave.,
<br />
<br />Grand Island, NE. 68803
<br />'-l'"j?b lJA fi:: ~ILED BY RF.GIS T"RAR" (Mo, Day, h.)
<br />
<br />_ JUL 1 0 2002
<br />
<br />32" REGISTRAR
<br />
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