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<br />D~~~F2s5uig~ <br /> <br />WHEN 1HS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMIWMRVicer-'o;:;-=-- <br />SYSTEM, rr CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORuiiN--~EV/lij;f~"o.~~"'"-7- <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE_qIQN,J/(HlCflIS-:~~_-~ <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. /,/-~"-~ ,~-=-\ '-' ~ <br /> <br />200707210 MIf/'u-U;'~t:~ L - --~c <br />JVVW' "UANL-rt s. CliOPEIr'"' <br />ASSISTANT S;ATEREGI,STRAR _ <br />_____~_____ _ _ HEA.~TI1A!!E_HU~!!_~~'t/P~!:ii:l~:S~__,=y <br /> <br />_ __'::'H.C;OI.N,!!E.I3~~!CA <br /> <br />4 <br /> <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br /> <br />. ". <br />....--~- <br />'h_ <br />. "-'~ <br />~~ .,,~.. ,.'. ----...,.,----':" <br />--:-..;;~:..=-.:=--'-'-""""--- <br /> <br /> <br /> <br />uNDER' YEAR <br />5b MOS DAYS <br /> <br /> <br />" DECEDENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />lAST <br /> <br />Omaha, Nebraska <br />-"II 7 SOCIAL SECURTIY NUMBER <br />.11 <br />~-. 507-20-6777 <br />.11 <br />~.J Sb. F ACILITY ~ Name (N not institution, give stTfJet ana nl,Jm/;JM) <br />II <br />-. 1720 N. Tavlor <br />8<'-CITY TOWN OR LOCATlOr<tOF DEATH <br /> <br />HOSPIT Ale D Inpatient OTHER 0 Nursing Home <br /> D ER Outpatienl [i] Residence <br /> D DOA D other (Specifyl <br /> <br />14.. USUAL OCCUPATION (GIVe kind 01 work donII during most <br />J] 01 tNOfking Iffe, flVfm if retiredl <br />Claims Re <br />'i1'6. FATHER - NAME MIDDLE <br /> <br />-.. <br />'41 Michael <br />Ie WAS DECEASED EVER IN U,S, ARMED FORCES? <br />(Yes. 1"10. Of unKI !If yes. give WAr and l1ates 01 S8l'Vlces) <br />Yes 1943 1946 <br />'9b INFORMANT MAILING ADDRESS <br /> <br /> <br />9. <br /> <br />NoD <br /> <br /> <br />19a. <br /> <br /> <br /> <br />:X:XI Burial 0 Removal <br /> <br /> <br />21e, CEMETERY OR CREMATORY NAM< <br /> <br />20 <br /> <br />210. METHOD OF DISPOSITION <br /> <br />C_tery <br /> <br />Kleine Funeral Home <br />22b FUN<RAL HOM< ADDR<SS ISTR<ET OR R.EO. NO" CITY OR TOWN" STATE, ZIP) <br /> <br />o Cremation 0 Dot"tah()(1 <br /> <br /> <br />3213 W. North Front St. <br />A T< US< <br /> <br />Grand Island <br />(ENTER ONLY ONE CAUSE PER LINE FOR 1_llbl. AND (ell <br /> <br />Interval een onset and dealt1 <br /> <br />o <br />.0 <br />) 0 <br /> <br /> <br />u...u.R. ff!-, <br /> <br />Interl/al between On$el and de<lltl <br /> <br />tnter~al between on5e'l and death <br /> <br />26_ <br /> <br />ALcdenl 0 undetermined <br />SUICide 0 Pending <br /> <br />Homicide <br /> <br />InvEtSliga1ion <br /> <br />26<>. INJURY AT WORK <br />Yes 0 No D <br /> <br />26g. LOCATION <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITy OR TOWN <br /> <br />STATE <br /> <br /> <br />(Mo.. Day. Yt.} <br /> <br />28.. DA TE SIGNEO (Mo. Day. Y'I <br /> <br />28b. TIME OF DEATH <br /> <br />~~i <br />~'" <br />I~O <br />"l=~ <br />.."'~ <br />~~~ <br />~~~ <br />~"'U <br />8 5 <br /> <br />M <br /> <br />28< PRONOUNCED DEAD (Mo.. Oey., Yt.} <br /> <br />2ad. PRONOUNCED D<AO (Heu'l <br /> <br />M <br /> <br />M <br /> <br />286. On the basis of examination and/or investigation, in my opinion death occurred al <br />tl'le time, date and place ancl c!u@to rhe cause(sl staled. <br /> <br />WAS CONS<NT GRANTED? <br />DYES <br /> <br />NO <br /> <br />e <br /> <br />(Mo., Day, y'.j <br />